26H Module 1 & 2

Define Health Systems

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

What are the key components of the healthcare system?

primary, secondary, tertiary, public health services

explain primary healthcare

• First point of contact with the health system

• Usually provided in the community / community-based → pharmacy, ambulance, Marae, workplace, general practice, telehealth service

• Looks at more ‘common symptoms’

explain secondary healthcare

• Specialised medical services → surgical services + uncomplicated hospital care (outpatient and inpatient services)

• Usually in a hospital setting but can be in the community

• In NZ, it operates via a gatekeeping system. Primary health care providers (typically) control access to secondary healthcare services through referrals

explain tertiary healthcare

• Typically hospital-based care → dealing with high complexity conditions → such as serious illnesses + injuries, cancer management and complex surgeries

• High cost (referring to money, people resources, time) to the health system

• Blurred boundary between secondary and tertiary

explain public health services

• Definition: all of the measures in society that are there to prevent disease, promote health and prolong life

• Focuses on

- prevention of disease progression (e.g. screening, immunisation) → anything with a preventative measure is public health

- health promotion + health education

- environmental health + communicable disease (disease that is spreadable) control → e.g. lockdowns, mask mandates

What makes public health distinguishable from other health areas?

• focuses on groups of people rather than individuals

  public health is population focused while primary/secondary/tertiary care focuses on improving health outcomes of the individual

• keeps people well → maintenance

example of primary care providers

GP’s, midwives, dentists, physiotherapists, occupational therapists, nurse practitioners, community pharmacists, paramedics

example of secondary care providers

cardiologists, radiologists, urologists, dermatologists, speech therapists, psychiatrists

where is primary care located

Usually provided in the community / community-based, but some receive primary care within hospital/emergency department due to not being able to access a primary healthcare provider

where is secondary/tertiary care located

Usually in a hospital setting but can be in the community, e.g. Manukau Super Clinic

where are public health services located

mostly non-clinical, but prevention + health promotion takes place in primary care settings (e.g. GP/nurses offer vaccination or screening)

What does a health system essentially do?

• policy

• management

• funding (pays those who provide health goods + services, raising funds, insurance, taxation)

• research + development (treatments, patterns of illness and dis-ease, health services research)

what are the three types of functions that you can have with players (organisation/entity that participates) in the health system

Provider, payer, and policy

What are Provider organisations?

Provide care, provide for the health interests of patients → meaning that they supply any type of goods or services (mainly within a clinical setting)

What are Payer organisations

• Decides where money goes/what will be funded + which services will be paid for and for and how much they are paid

• Creates contracts with health providers

• They work out what an organisations' contract is, regulate how much the organisation can charge for services, how much funding they will give (more funding = patients pay less) → co-payment

What are Policy organisations

• Running the health system as a whole

• Make decisions + steer the direction of the health system → focuses on what should be done and how

• Goals, directions, is equity being reached? All these aspects come under policy players

Can organisations have multiple functions?

yes

What were the Ministry of Health’s old responsibilities?

• Multiple function organisation

• The NZ central public sector organisation for health

• main body that advises the Govt. on all public health matters →  Develops and advises on policy for health and services 

• implements policy

• Answerable to the Minister of Health

• Receive funding via taxation + determines how our health system budget is made + pays (contracts) for some services

What is PHARMAC?

• Crown Agent Organisation → determines how our Government pharmacy budget will be spent → Have the power/are able to dictate what pharmaceuticals are funded 

• Buy medication in bulk for the country → ensuring access to low cost/free prescriptions

• Payer for pharmaceuticals

• Consider: do they apply an equity lens to these decisions?

What is ACC?

(accident compensation corporation)

• Will cover healthcare costs if anyone has an accident (no-fault compulsory insurance scheme)

• Answerable to the minister of health

• Social insurance

• Payer which contracts/pays health providers to cover accident victims (at no personal cost)

What are District Health Boards (DHBs)?

• disestablished

• Crown Agent Organisations funded by the Ministry of Health

• 20 decision making bodies → varied in decision making → zip code lottery

• Made local policy decisions

• Dictated how they would distribute the funding they received based on the needs of their community/area + contracted local for-profit and nonprofit providers

What are Primary Health Organisations (PHOs)?

• disestablished 

• Private non-profit organisations

• Purpose to promote and maintain health → umbrella over community services

• Provide primary care to enrolled populations

• Funded by MOH and DHBs to then provide funding for family providers

• Funding distribution was determined based on the populations (who were enrolled in a certain area etc.) → e.g. funded GP’s on a capitation basis (which is  based on the numbers of the enrolled with general practices who belong to a PHO population)

What is the role of general practices/practitioners?

• Main body that advised the Govt. + MOH about health services

• Private businesses → they can choose/determine what they charge patients → profit

• Providers of primary healthcare services to patients

What are non-profit providers

• Main body that advised the Govt. + MOH about health services

• Set up to serve specific groups + communities → promote services so that they respond better to Maaori and Pasifika patients

• Promoting a ‘by Maaori for Maaori / by Pasifika for Pasifika’ approach → DHB had contracts with them to fill gaps in the system and attend to diverse needs

• Implements a Te Tiriti lens + Kaupapa Maori approaches (which are beneficial for everybody)

• Provide primary health care and disability services within communities.

What caused a restructure to the health system?

2 reports/findings:

• Health and Disability System Review, commissioned by the Govt. but it was carried out independently

• WAI 2575 Report - Kaupapa Outcomes Inquiry, completed by the Waitangi Tribunal

Describe the Health and Disability System Review

Advise the Govt. on a future health and disability system that is sustainable, is well placed to respond to future needs of all New Zealanders, and shifts the balance from the treatment of illness towards health and wellbeing

Looked at health system as a whole → equity, quality if care, access of care, cultural competency

Describe the WAI 2575 Report - Kaupapa Outcomes Inquiry

The legislative, strategy and policy framework fails to state consistently a commitment to achieving equity of health outcomes for Maaori

Essentially, the health system is creating/maintaining inequities for Maaori

Health and Disability System Review findings:

• Complicated + fragmented system

• Lack of leadership + cooperation

• Inequitable health outcomes cannot be addressed by the health system alone

• Maori have not been well served → in terms of quality and access of care + longevity (care over time)

• System does not respond to patient needs and creates many barriers in accessing health care

WAI 2575 Report - Kaupapa Outcomes Inquiry

• No effort in ensuring the whole health system complies with Te Tiriti

• Situations of underfunding, understaffing, underrepresentation, cultural competencies and overall inadequate, inequitable health care service

• Failure to monitor and evaluate health sector → therefore it is never clear whether certain strategies are actually helping

• Failed to design a system in partnership with Maaori → there needs to be more flexibility and catering to Maori, and to those with specific needs

Health System Challenges

• Complex system → too many decision making bodies

• Institutional racism

• Inequitable outcomes for Maaori, Pasifika and those living with disabilities

• Lack of focus + investment in primary and community care

• Postcode lottery: DHBs determined decisions for funding and provision in their area → every area is different → individual health + access + quality depended on where you lived

What is the Pae Ora (Healthy Futures) Act 2022?

a legislation to restructure/form new health system

What did the Pae Ora (Healthy Futures) Act 2022 do?

Established 3 new entities

• Public Health Agency

• Health NZ (Te Whatu Ora)

• Maori Health Authority (Te Aka Whai Ora)

  + Created a formalised role for Iwi-Maaori Partnership Boards

Why was a formalised role for Iwi-Maaori Partnership Boards created?

So that they can properly provide their opinion/advice + voice their needs for their communities/hapuu/iwi (have more say) → There were already Iwi-Maaori Partnership Boards however this Act ensures that they legally have a say in health matters

Aspects of the Pae Ora (Healthy Futures) Act 2022

• Aims to improve the health of everyone in Aotearoa, focusing on eliminating health inequities

• Current system

• simpler/more streamlined

• Less fragmented → less players → more central decision making body

New Role of the Ministry of Health (Manatuu Haoura)

• Still responsible for setting health strategy → continues to play crucial oversight role

• Day to day role will shift to new entities

• Other functions given to the Public Health Agency (PHA) → 

• No longer a direct connection to communities anymore

Role of the Public Health Agency

• dedicated purely to public health (which we did not have before)

• leads all public health and population health policy, stargey, regulatory, intelligence, surveillance and monitoring functions

• Key role in providing advice to Ministers on all public health matters

Role of Te Whatu Ora (Health NZ)

• Took other responsibilities of MOH → day-to-day running of health system

• Picked up the functions of the DHBs and the primary health care organisations (20 DHBs and approx. 30 PHOs) → so that the can plan and provide hospital and specialist services nationally to avoid postcode lottery

• Primary and community services planned + purchased through localities (similar to DHBs) → smaller → larger focus on wellbeing

• Implemented first Pasifika health director → to have a voice on Pasifika health inequities → Current director: Markerita (Meg) Poutasi

What are localities?

A branch of Te Whatu Ora that talk to iwi partnership boards, focusing on very specific needs of the community → Same objectives as DHBs but on a smaller scale + more in depth → larger focus on wellbeing

Role of Te Aka Whai Ora (Maaori Health Authority)

• Monitors overall performance of the health system, to reduce health inequities for Maaori

• Partnership with Manatuu Hauora (Ministry of Health) and Te Whatu Ora (Health NZ)

• Leading change for responsiveness to Maaori (developing strategy + policy to drive better health outcomes)

• Commissions kaupapa Maaori services and other services targeting Maaori communities

What are the ways health care can be funded in different health systems

Health Systems are (predominantly) funded through:

• Taxation

• Direct payment (or out-of-pocket or user-pays)

• Insurance

• Social Insurance

Describe public via taxation funding

Taxes are collected from the public → goes to the Government (where they allocate how much health expenditure the Whatu Ora receives) → Te Whatu Ora determines how the funding is distributed in the health system/how health services are commissioned.

Pro of public via taxation funding

Pools the risk of ill health across the population → if someone needs more health care, it is not dependent on how much they earn (because the whole country pays taxes) → Equity based

“Access is not dependent on how much you can pay”

Tensions of Public via taxation model

 tax is not only dedicated for healthcare → Government pays for defence, transportation, public welfare, social welfare etc. → tax may not cover all aspect of healthcare

Te Whatu Ora decides what is funded and may not fit for everyone, eg; rare diseases.

Describe Health Insurance (Private)

Individual + their employer pay a premium (pays money to private insurers, which then cover the cost / pay health providers when you need to access + use care)

Pro of Health insurance

95% of things are subsided - high quality health care.

Tensions of Health insurance

•  Not all healthcare is always covered → causing people to pay directly for health → access to health services is dictated by ability and willingness to pay for health

• Not always aimed to get the best health - they focus on profit.

• Promotes the idea that our health is our individual responsibility. Victim blaming.

• our ability to pay, determines the quantity + quality of healthcare

Describe Social Health Insurance

Employees and employers (usually) put together a sickness fund → contribute regularly to a sickness fund that then funds for your health services

Pro of Social Health Insurance

• Pools risk of ill health across the population

• Focuses more on social solidarity → means that everyone that has access to care + (should be) interventions in place for those that are unemployed

• Employers must pay into the fund.

Tensions of Social Insurance

• Limited scope: Sickness funds may not always cover everything required for health care.

• Employer doesn't always match how much the employee puts into the sickness fund.

From Lottie (simplified answer): when ill executed → the rich are paying less than what they actually could afford to pay for healthcare, at the expense of overcompensation from lower income earners → can drive equity gaps between socio economic statuses and health.

Describe Direct Payment

When you access certain health services (especially private businesses → as they are “for profit”), you usually have to pay out of pocket

Government also gives money to health services, so that patients pay a co-payment instead

Pro of user pays

ask the others lol

Tensions of user pays

Access to health services is dictated by ability and willingness to pay for health

Defers people who need health care.

Sees health as an individual responsibility

How is ambulatory care (medical care provided in the community) in NZ funded?

• Primary care → From mostly direct payment to mostly tax, some direct payment and private insurance

• Private secondary (specialist) → Direct payment, private insurance

How are hospitals in NZ funded?

Mostly tax some private insurance

How are pharmaceuticals in NZ funded?

Mostly tax, some direct payment, some private insurance (if you need medication that Pharmac does not fund, it can be covered via private insurance)

How is public health in NZ funded?

Tax

What kind of funding system does NZ have?

Aotearoa has a Dual system → “A dual system means that we have two predominant ways/methods that we fund health in Aotearoa → Public funding (taxation) + Private funding (insurance + out of pocket)

Health system definition

“All activities whose primary purpose is to promote, restore, or maintain health.” (WHO)

3 Health System Fundamental Objectives (WHO)

1. Improve the health of populations (health outcomes → e.g. mortality, morbidity)

2. Respond to people’s expectations (responsiveness) → how well the health system caters to every individual’s needs

3. Provide financial protection against the costs of ill-health (fair financing) → if you can’t afford health you should still be entitled to it

   We measure performance through these 3 objectives

How are the WHO health objectives measured?

 access, quality and efficiency

Describe Access

• Are services offered in a specific geographic area? (distribution)

• How easy it is to get care? (barriers)

List what comes under Quality

• Quantity

• Clinical Quality

• Service quality

Describe Clinical Quality

skills levels, correct diagnosis and treatment, the right resources being available to carry out appropriate care

Describe Quantity

How much care is given

Describe Service Quality

amenities, convenience (waiting times), interpersonal (polite, information that is provided to patients, etc.)

List what comes under Efficiency

• Allocative efficiency

• Technical efficiency

Describe Technical Efficiency

Are goods + service produced at a minimum cost?

Describe Allocative Efficiency

Are the right outputs (services) being produced to achieve our goals?

What did Robin Gaud (2013) say about the health system?

“New Zealand [has a] health care system that performs anywhere from poorly to superbly depending on which of the many indicators one looks at.“

How does the NZ health system perform?

mixed performance

How does the NZ health system perform in terms of access?

• Good access to pharmaceuticals

• Long waiting times for non-emergency surgeries

• Poor access/equity for primary care due to cost

• Difficulties in getting after-hours care

• Waiting over two months for specialist appointment

How does the NZ health system perform in terms of quality?

• Mid-ranking results on most quality measures

• Slower take-up of new medical technology

• Shortages of health professionals

• Avoidable hospitalisations for diabetes, asthma

• Before Te Pai Ora Act: Clear failure of the Health and Disability system to uphold Te Tiriti obligations

• Before Te Pai Ora Act: Failure to focus on inequities that we have as Maori and Pasifika, that immediately means we are more likely to be unhealthy and live in unhealthy environments (due to factors/events in society, such as colonisation), and also less likely to get health to support us

How does the NZ health system perform in terms of efficiency?

Mixed health system performance, but costs less than other countries

How do Penchansky & Thomas (1981) define access to healthcare?

it is a “concept relating to the degree of ‘fit’ between the clients and the system” 

• Talking about how well the health system actually caters to our needs in a way that we can access healthcare

How do Levesque, Harris & Russell (2013) define access to healthcare?

it is “the opportunity to reach and obtain appropriate health care services in situations of perceived need for care”

• As clients we should be able to identify when we have health needs and then be able to access healthcare based on those health needs / having them managed in a way that we find appropriate and effective

What are the different dimensions of access to health care as described by Penchansky & Thomas?

availability, acceptability, affordability, accommodation, accessibility (geographical)

Define + Describe Availability

Definition: It is the volume and type of services relative to clients needs

• Measures the extent to which the provider has the requisite resources (such as personnel and technology) to meet the needs of the client → just means whether the volume and type of services needed by the community are available

• E.g. Do we have enough GP’s, do the GP’s have enough of this, of that? Do we have to go to another branch/service because the first place you went to didn’t have the provisions/resources on hand?

Define + Describe Acceptability

Definition: How the patient feels about the characteristics of the provider (and vise versa)

• Cultural and social factors determining the possibility for people to accept the aspects of the service ( and for services to accept aspects of the patient) and the judged appropriateness for the persons to seek care → Emcompasses ethnic background, gender, class, culture

• E.g. is a woman is going in for a cervical screening, is there a female practitioner available? → are our identity, gender, sex etc. reflected in the health care services?

Define + Describe Affordability

Definition: The relation of prices of services and the client’s ability/willingness to pay

• The economic capacity for people to spend resources and time to use appropriate services

• When mentioning affordability: Always state whether it is a direct or indirect cost → Even if healthcare was “free,” it wouldn’t actually be free → we would be paying elsewhere

• E.g. won’t seek out services due to cost / won’t get their precription due to cost

Define + Describe Accommodation

Definition: The relationship between the manner in which the supply or resources are organised to accept the client and the client’s ability to accommodate to these factors

• Measures the extent to which the provider has the requisite resources (such as personnel and technology) to meet the needs of the client → just means that the volume and type of services needed by the community are available

• Reflects the extent to which the provider’s operation is organised in ways that meet the constraints and precedences of the client → includes structural aspects(how the health system is built)

• E.g. Opening hours, Telephone services, How appointments are made

Define + Describe Accessibility (geographic)

Definition: The relation between the location of supply and the location of the clients

• Measures the extent to which the provider has the requisite resources (such as personnel and technology) to meet the needs of the client → just means that the volume and type of services needed by the community are available

• E.g. People residing in rural areas could travel for hours to access certain health services (e.g. specialised services)

Where is the following definition from and what is it concerning?

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

Health System as defined by the World Health Organisation

Where is the following definition from and what is it concerning?

The opportunity to reach and obtain
appropriate health care services in
situations of perceived need for care

Access as defined by Levesque, Harris & Russell
(2013)

Which of the 5 A’s does the following statement refer to?

The relationship of prices of services
and the client’s ability to pay

Affordability - Penchansky & Thomas (1981) (1981)

Which of the 5 A’s does the following statement refer to?

How the patient feels about the
characteristics of the provider (and vice
versa)

Acceptability - Penchansky & Thomas (1981) (1

Which of the 5 A’s does the following statement refer to?

The relationship between the manner in
which the supply or resources are
organised to accept the client and the
clients’ ability to accommodate to these
factors

Accommodation - Penchansky & Thomas (1981) (1

Which of the 5 A’s does the following statement refer to?

The relationship between the location of
supply and the location of the clients

Accessibility (geographic) - Penchansky & Thomas (1981) (1

Which of the 5 A’s does the following statement refer to?

Volume and type of services relative to
client need

Availability - Penchansky & Thomas (1981) (1

What were some findings of the NZ Health Survey (2019-2020) regarding access to health care?

• 29% of Maori adults were unable to get an appointment with regular medical centre within 24 hours → could not access primary care + secondary care (due to gatekeeping)

• Maori (2.8x) & Pasifika (2.6x) more likely to report being unable to collect a prescription due to cost

• 20% Maori & 16% Pasifika reported unmet need for GP services due to cost (vs 13% NZ European)

• transport is more likely cited as a barrier to accessing health care

What is a potential solution for improving access to health care for Māori and Pasifika peoples in Aotearoa?

Increasing facilitators of access to health care. This means:

• Having Pasifika-led, Maaori-led organisations 

• Health workforce representation

• Health navigators & support services that reflect Maaori and Pasifika worldviews

• Cultural competency & cultural safety

• Telehealth services

• ‘Patient-centred’ approach – cost, appointment, opening hours → facilitating care for Maaori and Pasifika

Name 2 facilitators of access to health care

• National Hauora Coalition

• Alliance Health Plus

  check with others for more examples

What is the National Hauora Coalition?

• Maori led PHO

• improve outcomes in wellbeing, prosperity & equity

• Mana Kidz → Healthcare is delivered by registered nurses and whānau support workers within schools.

What is Alliance Health Plus?

• Pasifika led PHO

• Grow the Pacific health and wellbeing workforce + decrease the health equity gap

Define social determinants of health

The structural determinants that generate or reinforce social stratification in society (Solar & Irwin, 2010)

Define social stratification

“the hierarchical arrangement of individuals in a society based on factors such as wealth, race, education and power (also, resource allocation & class systems)” (Solar & Irwin, 2010)

Describe the impact of the SDoH on health

They dictate health opportunities / the opportunity to obtain and maintain healthiness of social groups based on their placements within these within hierarchies of power, prestige and SES → where you sit in the hierarchy dictates what type of social determinants you have access to

SDoH dictate your health outcomes → they dictate how exposed we are to them → can be positive + negative → is it the distribution of the SDoH that determine whether we are healthy or not

Describe the Biomedical view

approach to health based on treating biological and physiological illness

Describe the Biopsychosocial view

approach to health based on surface causes → how health systems and health society affects an individuals health

Describe the Critical Public Health view

 acknowledge that social status, ethnicities & basic causes such as racism affect our health → not acknowledged in other “views”

example: TKHM Model → offers a model to show that racism and unfair treatment at the institutional level causes poor health outcomes for Maaori and Pasifika