Analysis: Experts have endorsed the new approach to public health but say the scale of funding and the agency’s resilience to food and tobacco lobbyists will be key, Marc Daalder reports
For years, public health experts have unified around a single concept: New Zealand needs a centralised public health body.
“All of us in public health would have liked to have seen an independent public health agency. I don’t know a single senior health professional who wouldn’t like to see that,” Jim Mann, an expert on non-communicable disease at the University of Otago, told Newsroom in June. At that stage, a landmark review of the health system had proposed wideranging reforms, but failed to recommend a new public health agency.
Now, however, that is about to change. On Wednesday, the Government announced its response to that review, which includes replacing the 20 District Health Boards with a national agency, Health New Zealand, and the creation of a standalone Māori Health Authority.
The reforms will also set up a new Public Health Agency to develop strategy and policy within the Ministry of Health, while the 12 existing Public Health Units will be consolidated into an operational entity within Health NZ, called the Public Health Service.
Shouldering the pandemic response
Ayesha Verrall, a former University of Otago public health expert who is now the Associate Minister of Health for public health, told Newsroom that the Public Health Agency would be in place by July 2022. Already, officials are devising a transition plan to move the Covid-19 pandemic response from the ministry to the new public health body.
“The Public Health Agency should build on the ministry’s skills in regulation and technical expertise and surveillance [testing]. All things that we’ve had to bolster the ministry during the pandemic because of the massive amount of work that’s needed to be done,” she said.
Health Minister Andrew Little indicated the new Public Health Service would maintain the regional infrastructure of the 12 units it absorbs, but will have a nationwide scope. That means it could better respond to a localised public health emergency by redeploying staff and resources from other localities while also more effectively operationalising national public health policies.
Verrall said the service will preserve the best of both worlds.
“Health New Zealand will contain the 12 public health units and we want to keep their strength as local experts that really know their community well. That’s been a really critical thing about getting through the pandemic,” she said.
“New Zealand didn’t choose to go down the call-centre-only model of contact tracing where we bypass local expertise. We sought to augment local expertise with good IT and central resource.
“That has to stay, but there’s an opportunity through having one service to make sure that we have consistent protocols about how we manage nationally significant health threats and use the expertise that’s currently distributed nationally to raise standards across the country.”
Experts in population health have greeted the proposals with cautious optimism, saying they would have preferred a standalone agency that combined operational and policy development capabilities sitting outside the remit of the Ministry of Health but that the reversal of decades of fragmentation was an important step.
“Obviously it’s a huge improvement on where we’re at, in the moment, in capacity,” University of Otago public health expert Michael Baker told Newsroom.
Baker’s fellow epidemiologists at the University of Otago, Amanda Kvalsvig and Nick Wilson, agreed.
“I believe there is tremendous potential in these health reforms. The reforms include several bold moves that are appropriately scaled to the need for transformational change. The challenge will be to realise the exciting potential of these reforms and truly make a difference in people’s lives,” Kvalsvig told Newsroom.
“The establishment of a Public Health Agency is very welcome. The lack of such an agency was an important gap in our pandemic response last year and could have been disastrous if the public health community hadn’t stepped forward in the way it did.”
Health experts like Baker, Wilson and Kvalsvig have long pushed for a public health body.
Speaking about New Zealand’s rocky path towards eliminating Covid-19 in April 2020, Baker said, “Even though our Ministry of Health has done, I think, very well, it still clearly has not enough staff to do this properly. Also, for policy-making agencies, it’s hard for them to take almost a wartime or civil defence mode of operating. There’s no accident all around the world, pretty much every high-income country has a dedicated public health agency. Public Health England, Scotland, Wales even, Ireland, CDC in the US, Public Health Canada. New Zealand’s really out on its own a bit.”
A standalone agency?
Wilson said he would have preferred to see the Public Health Agency set up as a standalone agency like PHARMAC or the Health Quality and Safety Commission.
“Then there’s less risk of it being absorbed into the ministry. Even from the Covid situation, it was all hands on deck – people in various parts of the ministry were all diverted. If you have a separate agency, then that sort of diversion is less likely. People can stay focused on the task at hand. But, it’s still better than the current situation because if it’s got some demarcation it’s good.”
Verrall acknowledged that there would be some benefits to a standalone agency, but said the ministry couldn’t afford to be stripped of all of its public health expertise.
“We had to reflect on the experience we’ve been through with the pandemic and just how important it is to make sure our ministry has a critical mass of technical capacity and regulatory and policy strength. Faced with a decision about having a different agency outside or inside, we felt the most logical thing was to strengthen the ministry,” she said.
Baker said previous public health branches of the ministry had been dismantled. However, he and Wilson were both hopeful that sitting within the ministry might protect the agency from being shut down under pressure from food, tobacco and alcohol lobbyists, as occurred with the Public Health Commission in the 1990s.
“The advantage of it staying in the ministry is that it is harder for it to be killed off by corporate industries that have vested interests, like Big Food, Big Alcohol, Big Tobacco,” Wilson said.
“When the Public Health Commission was going, they could focus their efforts and get their political support mobilised to destroy the Public Health Commission. They didn’t like the commission’s advice, particularly in the tobacco and alcohol area. If it’s a seperate agency outside of the ministry, it’s easier for them to kill it off.”
Verrall said she expected the new agency would stand the test of time.
“That was another factor for putting it within the ministry is that an independent advocacy voice can just be defunded by an unsympathetic government and that is my analysis of what happened in the 90s. But I see the Public Health Agency as the legacy of the pandemic and I think, for decades to come, it will be a very brave government that gets rid of it,” she said.
The epidemiologists were also hopeful that the Māori Health Authority could play a role in public health policy where Māori experienced poorer outcomes.
Baker said one of the key issues that determined how successful the new systems would be was resourcing.
“On paper it looks positive. It all comes down to implementation and resources, because if you took the current resources and just shuffled them around into new entities, that wouldn’t necessarily help,” he said.
“It’s usually resources and mandate are what is needed for agencies to get things done. It’s mainly the ability to influence things outside the health sector.”
Achieving better outcomes in public health required changes to tax policy, food and alcohol regulation and housing quality, Baker said.
Kvalsvig made similar arguments in her comments to Newsroom.
“Reorientating health agencies toward prevention has great transformation potential. However, meaningful change can never happen if prevention is limited to individual action. Real change in population health requires change in the drivers of population health: the structural conditions that allow poverty, commercial interests, racism, and colonisation to shape people’s lives,” she said.
Would the Public Health Agency be able to weigh in on those areas? Verrall said it would.
“I think the Public Health Agency will be able to provide high-quality advice and strategic leadership on where we should be going with tobacco, as the ministry currently does, and some of those other noncommunicable diseases and threats. To find out what the best cancer prevention, diabetes prevention should be, it totally should be coming from [the Public Health Agency],” she said.
“What’s really promising about the reforms is the promulgation of those recommendations through Health New Zealand, backed up by funding. That requirement to develop national, regional and locality level plans so that we’re actually doing that work of preventing diabetes through community-based programmes ot promote exercise and a healthy diet, for example. DHBs have had so many other pressures [that] those sorts of innovations haven’t tended to get funded.”
Expanding the vision of public health
“How would you know that the system was going to function effectively and deliver outcomes that, in hindsight, we’d all say were the right things?” Baker asked.
“I would imagine almost all New Zealanders would say we want to see the end of tobacco-related illness in New Zealand, we want to see the obesity epidemic and diabetes managed so the impact is minimised, we want to feel safe in this country that we’ve got agencies that are keeping an eye on emerging [health] threats and are going to take decisive action if needed,” he said.
“There’s a whole lot of functional outcomes that people want. These are the things that we would expect. Will those [new] agencies deliver these things better than what we have at the moment? I would say yes.”
But Verrall sees opportunities for progress beyond disease alone.
“Public health really narrowly defined is communicable disease control and then noncommunicable disease has been an area of public health activity more recently,” she said.
“But I think there’s another area where I think the reforms could allow a lot of progress and that’s community-level programmes. That includes things like Well Child Tamariki Ora and the primary care maternity system.”
As it stands, these sorts of services are funded piecemeal by DHBs and the ministry.
“Currently, we fund single disease projects. Maybe a DHB and the ministry could be funding 50 of them just in a neighbourhood in Porirua, for example,” Verral said.
“We now have the opportunity to think much more holistically about what’s happening in a community and set a plan that responds to the needs of that community and which joins up activity and rewards collaboration between the various different providers. A lot of things are provided in a very fragmented, bitsy way, and I think one of the greatest opportunities presented by the reform will be in that area.”