By Tim Tenbensel.

By design, the 100-day mark of the new coalition government has attracted sizeable media attention. It is driven by a political marketing focus in which the Prime Minister Christopher Luxon can say after 100 days “We told you what we’re gonna do, we’ve done it, and now we’re telling you what we’ve done,”

Five key changes affecting health services were part of National’s specific 100-day plan for health.[1] The introduction of security guards in Emergency Departments was the first cab off the rank. On Day 100 (8 March), Minister of Health Dr Shane Reti announced five health targets, including three that are identical to, or closely resemble those introduced in 2009’s National-led government.

In between, other health services policy items ticked off the list include expansion of the maximum age of eligibility for breast cancer screening from 69 to 74, and the commitment to develop a plan toward establishing a third medical school at the University of Waikato.

But the biggest item on the list was the disestablishment of the Māori Health Authority (Te Aka Whai Ora). This required the passage of an Amendment to the Pae Ora Act which was passed under urgency on 28 February.  The amendment removed Te Aka Whai Ora, and all references to its relationships with other entities from the Act.

In addition, the Pae Ora Amendment delayed the establishment of Localities. These are 60-80 local networks of non-government and government health sector and community organisations that co-design and deliver local, community-based health services. Under Pae Ora, all areas of the country were to have Localities established by July this year, and plans produced by July 2025. This timeline has been pushed out by five years under the Amendment.

However, many structural changes introduced by the Labour government in 2022 remain. Despite having misgivings about the recentralisation of the health system, the government has not reversed the merging of 20 District Health Boards into Te Whatu Ora (Health New Zealand). The Minister of Health has also indicated that Iwi-Māori Partnership Boards (IMPBs) will have a significant role in the health system. But with the removal of Te Aka Whai Ora and hitting the pause button on Localities, it is not yet clear what this role will be.

The clear public relations-driven strategy underpinning the ‘need for speed’ entails some policy and political risks. For some parts of the 100-day plan, these risks are low. The health targets are a known policy quantity.  When health targets were last tried in the 2010s, some reported improvements were real, while others were achieved by smoke and mirrors (gaming). We don’t yet know how the government plans to avoid the unintended consequences of the last round.

The extension of breast cancer screening will face some implementation challenges around workforce capacity, and the rollout will be gradual. Both these policies will have reasonable support within the health sector organisations responsible for implementation.

The security guards in hospital emergency departments was a classic example a of PR-driven approach. Earmarked funding has already ceased, but Te Whatu Ora now bears either the cost of continuing to fund it, or the reputational risk of cutting it.

On the road towards a third medical school, progress to date is the signing of an MoU between the government and Waikato University. If it goes ahead, the soonest it will have an impact is in the mid-2030s.

The element of the plan where the need for speed could be a liability is the disestablishment of Te Aka Whai Ora. This was one of many instances in early 2024 in which legislative change was made under urgency. Although all governments have used urgency at times, none since the 1990s have used it so frequently.[2]

Unlike some other law changes, the dismantling of the Māori Health Authority had been clearly signalled before and during the 2023 election campaign and coalition agreements. Few people doubted that the coalition would follow through on its commitment. But it has exposed itself to unnecessary policy and political risks in the way that it carried out this commitment.

There was no clear practical need for the amendment to Pae Ora disestablishing Te Aka Whai Ora to be passed under urgency, without the scrutiny of the select committee process. This ‘speed without roadblocks’ approach may provide an electoral sugar hit for the coalition parties, but it could also sow the seeds for practical and political difficulties in health policy later in the parliamentary term and beyond.

While the parts of the Act referring to Te Aka Whai Ora have been excised, the Act retains its primary substantive focus on reducing health inequities, and the planning and reporting and accountability requirements still reflect this policy direction. To date, Minister Reti has avoided using the words ‘equity’ or ‘inequities’, preferring a generic focus improving health outcomes (including for Māori). Yet the planning and decision-making processes that are mandated under the legislation still require government health agencies to have a primary focus on addressing health inequities. The government may well decide to make further amendments to Pae Ora, but in the meantime the gap between the new government’s rhetoric and the policy priorities embedded in the legislation creates an existential bind for the Ministry of Health and Te Whatu Ora.

The 100-day strategy will also have dented Minister Reti’s chances of building positive relationships with health sector leaders and interest groups. Te Aka Whai Ora had widespread support from a wide range of health sector groups, and these groups, alongside everyone else who had a view or an interest, had no opportunity to have input on Te Aka Whai Ora’s disestablishment. Alongside the repeal of the Smokefree Amendment, and the looming prospect of health sector budgetary austerity, many conditions for a rocky relationship between government and the health sector may already be in place within the first 100-days. That is one achievement that the government may regret before the next election.

[1] Three of the five (not including the Waikato Medical school and security guards in Eds) were part of coalition government’s 100-day plan. The coalition’s 49 item plan did not contain any additional items relating specifically to health systems and services proposed by ACT and NZ First.

[2] https://www.rnz.co.nz/national/programmes/the-house/audio/2018928155/parliament-why-so-much-urgency