Evaluating medical technology in the context of a fiscal crisis: the case of New Zealand

Planning for health services in New Zealand, and the implications of increasing use of high technology, fail to take account of the mounting crisis in the country's economy. Social policy that ignores structural problems in the economy or the system of medical care is unrealistic. A strategy is advanced to determine what resources are likely to be available, and how they can be allocated to ensure value for money. The situation is not unique to New Zealand.     

The urban fiscal crisis in the United States, national health insurance, and municipal hospitals.

The fiscal stress which many U.S. cities are currently experiencing, the persistent problems of large-city local government hospitals, the recent decisions for selected public hospital closings in New York City and Philadelphia, and the prospective enactment of a program of national health insurance collectively raise questions about the viability of the nation's major municipal hospitals. While the majority of the nation's 40 largest cities are in a state of economic and demographic decline, the diversity which characterizes their fiscal conditions and their responses to fiscal stress suggests caution in generalizing from the highly publicized New York City experience in asserting the ability of cities to continue to maintain public hospital activities. Indeed, there is considerable evidence to indicate that the staying power of municipal hospitals is quite substantial even in circumstances of severe fiscal stress. Further, analysis of the effect of Medicaid implementation on municipal hospital utilization and of the impact of prospective national health insurance programs on the demand for and supply of medical services suggests that municipal hospitals will continue to be important providers of health care services for many years to come.     

A case study of health goals in New Zealand

OBJECTIVE: This paper outlines the New Zealand experience in using health goals and examines its strengths and weaknesses from an 'insiders's' perspective. METHOD: This paper reports on a review of the New Zealand health goals framework conducted in 1996-97. The review centred on a discussion paper, written submissions on it, and consultation meetings with the public, the public health sector and relevant government agencies. RESULTS: It is argued that the framework usefully shaped public health activity in New Zealand and should be retained with a focus on strengthening public health action. Health goals have been developed in New Zealand at a time of considerable change in the health sector. Although this change has been disruptive, it has also provided benefits such as the emergence of new providers. The strengths of the New Zealand framework have included: its inclusiveness, the consultation that occurred in developing it, and the monitoring and reporting system. Ongoing challenges, such as reorienting the health sector and developing a formal intersectoral strategy, are also identified. CONCLUSION: The paper concludes that the current health goals framework has the potential to frame future public health action in New Zealand, but that the increasing mainstreaming of the public health function poses some risk. IMPLICATIONS: The insight provided by the New Zealand case on the implementation of a health goals framework may assist public health planners in other jurisdictions.     

Setting goals and targets for performance standards within the Swedish health care system

The development of any health care system towards setting goals and targets and intended outcomes--with national guidelines, a legislative framework, limited resources, consumer influence and competitive forces--makes great demands on the control mechanisms required. The Swedish health care system has no tradition of goal formulation of this type. Hence, the purpose of this article is to clarify the goal-setting process of performance standards, and to examine whether goal setting is a relevant method within the organization of a Swedish county council. Goal setting can be seen partly as a control method and partly as an administrative process. The approach used is a combination of qualitative and quantitative methods. Data have been collected from interviews, observations, notes taken in the field and available performance statistics. The analysis shows that working towards a goal is made easier through a common and simple concept. It 'stands and falls' with the management of the work and its manager. Good communications and information are important prerequisites if goal formulation, through dialogue, is to succeed. This process takes time and can be described as an iterative process, in which a common behaviour pattern develops a 'we-feeling' which spreads among the staff. It is important that the goal is relevant and directly related to the basic objects of the work. It is also crucial that the goal is realistic and reflects a priority. Goal formulation relating to performance standards can be a contributing factor to staff's experience of job satisfaction through increased engagement and motivation, and to the satisfaction of patients/relatives with the care given. It is difficult to formulate performance standards; there are many problems and obstacles. If goal formulation as a control method within the health care system in Sweden is to work, clearer manifestations of political will are necessary and also better measuring methods in order to guage achievement.     

Developing the design of a continuous national health survey for New Zealand

Background

A continuously operating survey can yield advantages in survey management, field operations, and the provision of timely information for policymakers and researchers. We describe the key features of the sample design of the New Zealand (NZ) Health Survey, which has been conducted on a continuous basis since mid-2011, and compare to a number of other national population health surveys.

Methods

A number of strategies to improve the NZ Health Survey are described: implementation of a targeted dual-frame sample design for better Māori, Pacific, and Asian statistics; movement from periodic to continuous operation; use of core questions with rotating topic modules to improve flexibility in survey content; and opportunities for ongoing improvements and efficiencies, including linkage to administrative datasets.

Results and discussion

The use of disproportionate area sampling and a dual frame design resulted in reductions of approximately 19%, 26%, and 4% to variances of Māori, Pacific and Asian statistics respectively, but at the cost of a 17% increase to all-ethnicity variances. These were broadly in line with the survey’s priorities. Respondents provided a high degree of cooperation in the first year, with an adult response rate of 79% and consent rates for data linkage above 90%.

Conclusions

A combination of strategies tailored to local conditions gives the best results for national health surveys. In the NZ context, data from the NZ Census of Population and Dwellings and the Electoral Roll can be used to improve the sample design. A continuously operating survey provides both administrative and statistical advantages.

     

The New Zealand health reforms of the 1990s in context

The New Zealand health sector reforms of the 1990s have to be seen in the context of the long term development of the New Zealand health system. The evolutionary change between 1938 and 1990 was abruptly replaced by the revolutionary policy of commercialization from 1991 to 1993. This proved unsatisfactory, with the promised benefits such as significant productivity increases not occurring. In some ways the system functioned even more imperfectly, although this was in part due to the funding cutbacks which took place at the same time. The policy shifts from the mid 1990s have largely taken the New Zealand health system back to where it would have been, had the evolution up to 1990 continued. There remains unfinished business, the largest of which is that the tensions between the managers and the health professionals have not been resolved. The New Zealand experience provides strong evidence that comprehensive commercialization--business practices within, market relations between institutions--will not make a significant contribution to the design of effective health systems.     

Creating supportive environments for health: a case study from Australia in developing national goals and targets for healthy environments

Creating healthy living and working conditions are central goalsin public health which have re-emerged in prominence in thepast decade. The roots of thLs revival of interest can be tracedto include improved under standing of the relationship betweenliving conditions and health, prompting by the World HealthOrganiza non (WHO) through its ‘Health for All’strategy which has drawn attention to underlying causes of inequitiesin health in society, and a more general international concernwith ecologically sustainable development. Australia has respondeduniquely to the challenge of developing a strategy to createsustainable, supportive environments for health through itsNational Health Goals and Targets. These targets, publishedin 1993, include a range of targets for Healthy Environmentswhich were developed from a ‘health’ perspective,but in co-operation with the different sectors of governmentresponsible for action to achieve them. These include housing,transportation, education and employment. Early responses tothe publication of the targets are encouraging, but will requiresustained governmental support to reach fruition. Critical tosuccess in develop ing and implementing the targets will berecognition by government, and particularly the health sector,of the legitimacy of inter-sectoral action for health. Negotiations to resolve potential conflicts in the priorities of differentsectors should ensure that attention is focused on the commonground for practical inter-sectoral action to improve health.The Australian Targets Report identifies a series of concreteactions required to create supportive environments for health.A willingness to account for pro gress in achieving the targetsfor Healthy Environments will be an important measure of thecom mitment of the Australian federal and state governmentsto the health and well-being of their citizens.     

Setting goals in health promotion. A conceptual and ethical platform

Medicine, Health Care and Philosophy -     

Why people remain inactive during a crisis: Interpreting and dealing with a crisis within a broader social context

Public inactivity has been addressed by scholars across different academic disciplines. Risk communication and behaviour change is difficult and costly due to limited attention to various messages in the public sphere. Crises pose particular challenges if organisations are to communicate effectively with the public to protect them from potential risks. The present study attempts to better understand what makes the public inactive when faced with a crisis. Specifically, I focus on how people perceive a crisis and the reasons they remain inactive during the crisis. Using 28 in-depth interviews with Korean citizens during two food-related crises, this study revealed that people interpreted the crisis within a broader social context, made underlying assumptions in understanding the crisis and believed what the media vividly showed. The findings also showed that people remained inactive because they avoided dealing with risks due to being distracted by their daily lives, they trusted social systems to manage the problem, and they felt they had high efficacy in resolving the crisis although they did not expect to make fundamental changes in the long-run.     

The fiscal crisis in the health sector: Patterns of cutback management across Europe

PurposeThe article investigates trends in health sector cutback management strategies occurred during the ongoing financial and fiscal crisis across Europe.SettingA European-wide survey to top public healthcare managers was conducted in ten different countries to understand their perception about public sector policy reactions to the financial and economic crisis; answers from 760 respondents from the healthcare sector (30.7% response rate) were analyzed.MethodA multinomial logistic regression was used to assess the characteristics of respondents, countries’ institutional healthcare models and the trend in public health resources availability during the crisis associated to the decision to introduce unselective cuts, targeted cuts or efficiency savings measures.ResultsDifferentiated responses to the fiscal crisis that buffeted public finances were reported both across and within countries. Organizational position of respondents is significant in explaining the perceived cutback management approach introduced, where decentralized positions detect a higher use of linear cuts compared to their colleagues working in central level organizations. Compared to Bismark-like systems Beveridge-like ones favour the introduction of targeted cuts. Postponing the implementation of new programmes and containing expenses through instruments like pay freezes are some of the most popular responses adopted, while outright staff layoffs or reduction of frontline services have been more selectively employed.ConclusionTo cope with the effects of the fiscal crisis healthcare systems are undergoing important changes, possibly also affecting the scope of universal coverage.     

The political context of social inequalities and health.

This analysis reflects on the importance of political parties, and the policies they implement when in government, in determining the level of equalities/inequalities in a society, the extent of the welfare state (including the level of health care coverage by the state), the employment/unemployment rate, and the level of population health. The study looks at the impact of the major political traditions in the advanced OECD countries during the golden years of capitalism (1945-1980)--social democratic, Christian democratic, liberal, and ex-fascist--in four areas: (1) the main determinants of income inequalities; (2) levels of public expenditures and health care benefits coverage; (3) public support of services to families; and (4) the level of population health as measured by infant mortality. The results indicate that political traditions more committed to redistributive policies (both economic and social) and full-employment policies, such as the social democratic parties, were generally more successful in improving the health of populations. The erroneous assumption of a conflict between social equity and economic efficiency is also discussed. The study aims at filling a void in the growing health and social inequalities literature, which rarely touches on the importance of political forces in influencing inequalities.