POPULATION HEALTH 101 - term 1

Before modern health systems,what was important?

social and spiritual understanding of health/ illness, community, trust and intimate relationships mattered more than credentials

overtime, community roles became

professions

With the introduction of professions, what else changed?

Knowledge became recognised, training formalised, authority became institiutional

Profession

Recognised body of specialised knowledge with formal education and training, has autonomy over own work

Power and Hierarchy in health

not all professions have equal power, medicine has always dominated, depends on whose knowledge is valued most by society, power and boundaries renegotiated as professions emerge

Regulation

Protects public safety, sets standards of practice, controls entry into professions (2003 health practitioners competence assurance act)

Regulated professions are not more important, and unregulated professions / not professional body are not

less skilled

Self regulated def

a health profession takes responsibility for setting and upholding its own standards of competence, conduct, and ongoing professional development, often through a professional association

regulated profession

directly regulated by government through 2003 health practioners competence assurance act

How is the health care changing?

chronic conditions due to ageing demographic, emerging positions, health more focused on managment of conditions not cure, care across systems not just hospitals

Example of how the workforce is changing?

Kaiawhina and RN work together to deliver care and develop trust and relationships with members of the community that face barriers to access

Role of a kaiawhina

holds strong community and cultural knowledge to build relationships and trust with members of community

Different factors affecting health workforce means that compelx health problems require

multiple kinds of expertise, strong relationships across role, coordination and integration

Health roles have different power due to

legal authority, control over diagnosis and treatment, high autonomy

What do profession and boundaries do

organise work, protect standards and create friction

Authority def

what you are legally allowed to do

legitimacy def

what people accept you doing (new professions)

Friction example

by the nurse practioner introducing herself she avoided friction

hidden work includes

relationship building, explaining roles, cultural and contextual translation, preventing fragmentation

friction points

general practice funding models, professional boundary anxiety, organisation not ready for bew roles

Invisible work bridges the gap between

formal structure (regulation and authority) and the social system (legitimacy and relationships)

Why is differentiation necessary in health?

Specialisation creates expertise, boundaries protect standards, different roles organise work differently

Differentiation can cause fragmentation when

People have seperate goals, accountabilities and clinical languages

4 worlds of health

Care, cure, control and community

integration takes

effort

Some roles naturally fall into teams whilst others

remain peripheral or invisible

regulated roles and teams

often assumed to be in team spaces, easy

Self regulated roles and teams

not automatic, conditional acceptance into teams through explanation or justification

non regulated roles and teams

excluded from formal teams despite holding crucial knowledge

Teams require

time, space, permission, someone who controls boundaries

Social work in teams

Often sit at edge of clinical teams, bring contextual, relational and structural knowledge, integration and translation work

Maori and pacific teams

Kaiawhina, sit between services and communities, hold cultural and system knowledge, navigation, translation, often marginally structured in teams

Teamwork vs collaboration

Teamwork has defined membership with allocated time and space (surgery), whilst collaboration has negotiated membership and borrowed time and space

Example of teams

General practice, pharmacist and social worker come together for weekly meetings to share knowledge and integrate roles

Integration often

sits outside job descriptions, depends on organisational conditions, someone has to do stitching

1900-1940s medicine

became professionalised, Drs visited homes and hospitals to look after their patients, private, hospitals for caring not curing

New Zealand public health 1938

Prime Minister Michael Savage introduced Social Security Act which provides free healthcare however a well functioning system was never created, GPs opted to stay private.

Global trends 1940-1970s

Hospitals focused on curing not caring, greater medical specialisation, more effective control of infection making room for innovation, hospitals become focus of health system with more funding

NZ 1980

followed global trends, large number of small hospitals, centralised system (MoH), GPs paid throgh charge and subsidies, inconsistent and inequal acces to healthcare

Global 1980

Ageing population increase multiple chronic long term conditions that are complex in different areas, Technological change as people spend less time in hospital cause day surgery, Location of Care changes as deinstitutionalisation increases in mental health and hospital services become available in the community

What was introducedd to NZ in 1983?

Area Health Boards Act, 14 regional health boards with elected and appointed members who accomplish goals set by government and bring small hospitals together

What was introducedd to NZ in 1993?

Regional Health Authorities, down from 14 authorities to 4, hospitals become Crown Health Enterpirses (CHE), public but still required to make a profit to incentivise organisation, headed by non-health CEOs, PHARMAC ESTABLISHED

Big Bang Reforms

didnt work, Public Health Commision deestablished 3 years, vouchers for patient mobility never established

What was introducedd to NZ in 1997?

Health Funding Authority, responsible for personal health + public and social services, CHEs reconfigured and now 21 private companies that dont compete but still seperate from funder organisations

What was introducedd to NZ in 2000?

DHB, policy mostly from MoH and miniter, District Health Boards elected health boards, distributed funding to providers and had a large say on what policies meant locally, emphasis on primary care and integration between services

Why did continuous reforms before 2000 not work?

Politicians were looking for fame by constantly changing system, after 2000 reforms slowed and instead we began to focus on culture and integrating organisations

NZ 2000-2022

Many interventions to make primary care more accessible (Very Lowcost Access Scheme, Free Primary care for under 14), make parts more effective instead of changing whole system, Government - MoH - DHB

Ministry of Health

Key decisions and funding allocation (mostly to DHB, then to disability services), implements policy, develops and advises minister on policy

DHBs (district Health Boards)

Plan what goes on across different areas and then. fund it, provides services (hospitals, mental health), elected and appointed members, regional alliances involve several DHBs with shared decision making

ACC

Public sector organisation, funded by employer levies, taxation and vechile registration

GPs and Medical Centres

Private for profit providers, patient co pay with funding agreement form PHOs

PHO

primary healthcare organisation

Urgent Care

Afterhours, private for profit, GPs involved, copayments with ACC, centered around medical proffesionals

Other Private non-profit providers

Not centered around medical proffessionals (mental health, babies), maori and pasifika health providers

St John Ambulance

Private non-profit, funded by ACC, MoH and donations

Health and Disability system review 2020

Remove PHOs, add regions with districts in each, joint decision making with Iwi maori partnership

What happened to the reforms set up in 2020

Set up during pandemic with overworked workforce, not given enough time (especially Te Aka Whai Ora), lack of effetive leadership through difficulties didnt deal well with funding lower than inflation, no clear change and strategy

Change and confusion in 2020

Some functions of MoH were delegated to Te Whatu Ora, Te Aka Whai ora was established and deestablished, Te Whatu Ora is now first spender of health budget, Board replaced by commisioner then back again, DHBs turned into districts,

Culture in 2026

In 2024 Lester Levy was commisioner and 10/15 people in executive roles quit.

WHO objectives (2000)

Health status, Consumer satisfaction, Risk protection

Berwicks triple Aim (2007)

Improving health of populations, improving the experience of care, reducing cost per capita of care

Roberts Triple Aim (2008)

Quality, access, efficiency

NZ triple aim (2010)

Improved quality, safety and experience of care, Improved health and equity for all populations, Best value for the public health system resources

How is health defined according to the Biomedical model of illness (western)

An absence of illness or disease (lack of ease because parts of body arent working as they should)

How are diseases identified within the biomedical model

An identifiable abonormality from whats normal

What are the issues with the biomedical model

Mental illness is treated as less real because detection is difficult, patient os expected to remain powerless and do as doctor says (good most of the time but bad when doctors orders differ from patients needs)

Why is it important to look at the problems of the biomedical model?

Multiorgan disease end up getting worse treatment because people dont specialise with multiple different areas, some get treated as less real if there is no clear biological cause.

Examples of problems within biomedical model

Disease such as shellshock (PTSD), chronic fatigue and endometriosis are overlooked. Either no clear cause, no clear affect on organs (mental) or no treatment.

Many things that get missed in health are things that affect majority

women or minorities

Why is the moral behind biomedical models problems?

Our ideas of healthcare dont exist without context (culture), what matters depends on what we think to looks for and how we look for it (different normal for different people)

Functioning Limitations

Health defined by the individual based of what they are able to do (not what they cant). Example ICF, allows better patient assessment and personalised care strategies, improving overall health and experience.

WHO definition of Health

A state of complete physical, mental and social wellbeing and not merely the absence of disease

System definition

A set of things working together as parts of a mechanism or an interconnecting network; a complex whole

Three components of health

Absence of illness, capacity to function, complete wellbeing

WHO def of Health System

All activities whose primary purpose is to promote, restore or maintain health

Examples of other activities that affect health

Education, housing, nutrition, environment, peace vs conflict, sport and leisure, transportation

Quality in roberts triple aim

Healthcare service of a high standard, clinical (skill levels and diagnosis), service quality (amenities, convenience, interpersonal)

Why is quality important in healthcare

Maori are more likely to be given painkillers instead of treatment, maori are 1/3 more likely to be admitted with treatment injuries

Access in roberts triple aim

Service availible in area, affordability, availability when needed (shingles vaccine only free at 65)

Examples of access

Unequal access across country, more barriers for maori due to poverty and location (more doctors in rich areas)

Efficiency in roberts triple aim

Are resources being used well, technical efficiency (goods and services produced at minimum cost) and allocative efficiency (putting resources where they will have greatest value)

Examples of efficiency

Maori unable to receive treatment in timely and safe manner wastes money (especially if they come back worse),

20% of the differences in health status come from health system, where is other 80% from?

Education, housing, nutrition, etc.

Quadruple aim (berwick)

The experience of the healthcare workforce

Quintuple aim (berwick)

Health equity

How do we improve WHO objectives

Make sure Intermediate performance measures are working, which rely on policy and practice

What is missing from some of the triple aims?

Effieiency, equity, or explicitly focusing on patient care experience

Primary medical care

First point of contact normally, community / ambulatory, GP, midwives, physio, pharmacist etc.

Secondary care

Normally requires referrals from Primary care, typically hospital setting, specialised medical care

Exceptions to primary and secondary care

hospital emergency departments have patients requiring mix (ideally secondary care only), some community locations have specialist clinics, diabetes specialist nurse?

Tertiary care

secondary care that was too complex, often referred elsewher eg starship, often highcost

Public Health

Organised measures used to prevent diesease, promote health and prolong life among the population whole. Asses and monitor (information), public policies (address issues), enable access

Public Health Services

Prevention, Health promotion & education, environmental health and disease control

Public Health Services - Prevention

Medical care (immunisation, screening programs, tobacco control programs etc)

Public Health Services - Health Promotion and education

Educational not medical (nutrition education, drug & alcohol education, sexual health education)

Public Health Services - Environmental health and disease control

Broad (food safety, environmental contamination, drinking water quality, monitoring)

Why do distinctions exist in health?

Culture and organisations matter, history impacts today

Arrangements and domains

funding mechanisms differ and roles accountabilities very different (primary care nurse makes less money, public health given less resources)

Cinderella services

Where functions are seperated into different organisations which makes distributing resources harder and functions vulnerable.

Vulnerability of distinctions

When functions are split up, its easier to cut funding for public health or maori pacific health because people dont notice, 24% of roles in the National Public Health service were cut in 2024