Sophia Pi and Chris Bullen.
One of the greatest lessons from the COVID-19 pandemic has been the importance of a well-functioning public health service as part of the wider healthcare system. As the COVID-19 pandemic was unfolding globally, the New Zealand government implemented critical public health measures including lockdowns and border management to contain the spread of the virus, resulting in reduced Covid-19 prevalence and mortality rates.
The COVID-19 pandemic was one of a handful of communicable disease public health challenges in New Zealand (NZ) in the past decade, including notably the campylobacter outbreak in Havelock North in 2016 that revealed weaknesses in safe drinking water quality and a measles outbreak in 2019 that revealed a failure to maintain elevated levels of immunisation coverage across the population. In each of these cases, the government struggled to provide timely, coherent responses, in part because of our fragmented, under-resourced public health infrastructure.
New Zealand’s public health services have been historically underfunded and disjointed. However, to be most effective, public health requires long-term investments in collaborative, transdisciplinary solutions that address not only the immediate threats to population health but also the underlying factors that caused the issues to emerge in the first place: social and economic deprivation and inequities, inadequate unaffordable housing, and ageing sanitation and water supply infrastructure to name a few.
The health reforms in 2022 signalled an increasing government commitment to public health measures, with the establishment of a single Public Health Agency in the Ministry of Health, and the merging of 12 distributed regional public health units into a single National Public Health Service (NPHS) that sits within Te Whatu Ora.
The figure above shows the many entities that have a role to play in public health under the reformed system, and their relationships and connections.
The Public Health Agency (PHA), is the coordinating organisation for public health strategy, policy, regulatory and monitoring functions. The PHA is now responsible for leading all public health strategies across health and disability sectors and advising the Minister of Health on public health matters. The PHA also includes the Public Health Advisory Committee (PHAC), which consists of six advisory board members responsible for providing public-facing, evidence-based public health advice to the Director-General of Public Health.
The NPHS is responsible for enforcing health protection regulations and for health promotion – the former Health Promotion Agency (HPA) has been subsumed into the NPHS, and therefore health promotion programmes such as promotion of smokefree, SunSmart and alcohol harm minimisation are now part of the responsibility of Te Whatu Ora. This re-arrangement is evidence of a response to the findings of the 2019 Waitangi Tribunal Report and a 2020 Health and Disability System Report, which recommended changes to the healthcare system to address the fragmentation and inefficiencies that resulted in persistent health inequities.
Interestingly, the PHAC and PHA sit within the Ministry of Health, separate from Te Whatu Ora’s NPHS, but will be constantly communicating and liaising with this organisation. The Ministry of Health (MoH) has also undergone several changes, given that Te Whatu Ora is undertaking a significant part of MoH’s responsibilities. Under the new health reforms, the MoH now focuses on the long-term planning of NZ healthcare, advises on overarching health strategies, and regulates and monitors the health system. In addition, the Ministry of Health no longer oversees disability policies. That role is now the purview of The Ministry for Disabled People – Whaikaka, which was created under the health reforms to coordinate and lead disability services and policies across NZ.
Lastly, Te Aka Whai Ora, a separate agency from Te Whatu Ora, solely focuses on the health of Māori. In particular, the role of Te Aka Whai Ora is to significantly improve and advocate for policies and interventions that will improve the health of Māori and reduce health inequities experienced by Māori. Te Aka Whai Ora will have a close relationship with the newly formed Iwi-Māori partnership boards, local organisations covering a small population to support service planning and delivery for Māori at the forefront. Ti-Māori partnership boards are still in the process of development.
In what is a clear shift in direction away from the public health focus of the health reforms under the Labour-led government, the new coalition government plans to reverse some of these reforms, beginning with disestablishing Te Aka Whai Ora and replacing it with a Māori health directorate in the MoH. The impact of this change is yet to be seen. Most of the new health system structures for public health, such as the PHA and NPHS, are likely to survive the change of government but it is unclear if the level of resourcing they need to operate effectively will be reduced.
Another retrograde step for public health and health equity is the government’s intention to repeal the Smokefree Environments and Regulated Products Act, a piece of legislation that was expected to dramatically accelerate the decline in smoking and inequities in New Zealand to achieving the Smokefree 2025 goal.
Diversion of funding from ‘back end’ public health into frontline services has also been signalled. If so, it is a very short-sighted approach. Of course, we need more effective and equitable treatment services, but we also desperately need more effective, more agile, and more joined-up prevention and health promotion services.
And we need the resources to collaborate and co-ordinate with other sectors whose actions affect public health: local authorities, housing, education and many more – if we are to truly tackle the root causes of ill health.
