GUEST BLOG: Ian Powell – Kaitiaki Hauora – Together for Public Health; a powerful voice for the health system

Once a upon a time there was an ideological attempt in Aotearoa New Zealand to pretend that healthcare was a commodity, not a universal public good, and that therefore the health system should function as a competitive business market.

Creating this artificial market was misnamed the ‘health reforms’. It was enabled by new health legislation which took effect from 1 July 1993.

Simon Upton was the health minister responsible for the theoretical construct of the 1990s ‘health reforms’

The health system was radically restructured by splitting its purchaser and provider roles in order to create a competitive ‘internal market’

Crown Health Enterprises were created as state-owned companies required to run public hospitals under the Commerce and Companies Acts.

They were to compete with both each other and the private sector for service funding contracts with four purchasing bodies called regional health authorities.

These  pro-market, pro-privatisation ‘reforms’ were highly contentious at best. They were based on the false premise that market mechanisms would achieve greater efficiency.

Instead they resulted in high implementation costs, public opposition, and low morale among health professionals.

Like making a profit out of a soup kitchen

At the time then Medical Association Chair Dr Alister Scott perceptively described the ‘reforms’ as being designed by those who would try to make a profit out of a soup kitchen.

The Coalition for Public Health

In amongst the opposition was a remarkable organisation called the Coalition of Public Health. Its genesis was a group of medical specialists largely based at Wellington Hospital.

They were alarmed at the direction of the key government policy document that provided the foundation for the ‘health reforms’ known as the ‘Green and White Paper.

Over its nearly decade long history, the Coalition had three successive main spokespeople, all medical specialists.

Dr Peter Roberts, an effective spokesperson for Coalition for Public Health before he became senior doctors’ union president

They were Dr Alan Gray, a Wellington based oncologist; Dr Peter Roberts who subsequently became President of the Association of Salaried Medical Specialists (ASMS); and the above-mentioned Dr Scott. All proved to be very effective and persistent in this role.

In its engine room was journalist Lyndon Keene, the Coalition’s only  paid employee who also functioned as an occasional spokesperson to good effect.

What was amazing about this organisation was that with such small resources it convincingly outargued the exceptionally well resourced then National government and its agencies over the reality of the ‘health reforms’. It was real speaking truth to power.

The Coalition did this did this by resonating with the public through strong well-articulated advocacy and being evidence-based. Every well-articulated concern was supported by evidence.

Annette King was the health minister responsible for the repeal of this ‘internal market’ legislation

By the end of the decade some elements of the ‘health reforms’ were moved away from due to high unpopularity and by 1 January 2001 the governing legislation was repealed.

Strengthening collective force – again

I immediately thought of the Coalition of Public Health on 20 January after reading a media release announcing a new similar broad-based organisation formed to strengthen collective voices for healthcare: New national healthcare advocacy group formed.

The organisation is Kaitiaki Hauora – Together for Public Health. Its website is Kaitiaki Hauora | Together for Public Health | Protecting Public Health for all.

In its words:

The group has come together because of shared concern about the growing pressure on the public health system and the impact this is having on patients, whānau, communities, and the health workforce. 

At its core, our campaign has three big goals:

• Adequate and sustained funding to meet the real health needs of our population 
• Protecting and strengthening publicly provided healthcare, rather than outsourcing it to private interests 
• Honouring Te Tiriti o Waitangi by embedding equity, partnership, and Māori leadership in how health services are designed, funded, and delivered. 

Kaitiaki Hauora and its participants share a belief that publicly funded healthcare should be accessible to everyone, regardless of income or where they live, and that decisions about health and healthcare must be fair, evidence-based, and shaped by the people most affected. 

It has two spokespeople. One is retired intensive care specialist and former ASMS president (among many other things) Dr David Galler.

In his reported words:

We’ve come together because public healthcare matters to everyone. By working together across different parts of the health sector and community, we want to contribute to a stronger, fairer public health system for all – rich or poor, urban or rural.

Louisa Wall, the other spokesperson, speaks patients healthcare truth to health system political power (RNZ)

The second is Louisa Wall, Chair of the Tuwharetoa Iwi Māori Partnership Board and former Labour MP (and former netball and rugby international to boot).

Again, in her reported words:

For Māori, a strong public health system must be grounded in Te Tiriti o Waitangi and shaped by the voices of whānau, iwi and hapū. We’ve joined Kaitiaki Hauora because we believe publicly funded healthcare should be equitable, accessible, and designed in partnership with the communities it serves. 

Putting healthcare on the agenda

Dr David Galler brings an extensive experience of working within the health system

Dr Galler sums up well the dire straits the health system now finds politically imposed upon it in a Listener paywalled article (29 January): Putting healthcare on the political agenda.

Today,  our health services are under so much more pressure, increasingly overwhelmed by unchecked demand, hobbled by intermittent funding, short-term planning, and our choice to prioritise cost containment over investment. Now,12 years shy of its 100^th birthday, the survival of public provided healthcare is in real doubt.

The steady demise of the service has now reached a tipping point where all of us are affected by its inadequacies and failings. These are now glaringly obvious to the public, more so perhaps because of the current government’s overt disregard for the value public health services create and for the people working so hard to keep those services afloat.

As a result, many in our health workforce feel undermined instead of receiving the support they need to do what so clearly needs to be done. They have so much to offer but are seen more as a problem than part of the solution to the difficult issues we face and now feel so intimidated they are fearful to speak out.

Many of us who have been part of the health system for so long are aghast that, instead of investing to grow our services to meet need, those services are being privatised and much of that, funded from the public purse. That is not the right solution for the problems we are facing.

It does not add capacity to the health system, instead it diverts public money away from strengthening public hospitals and services and draws clinicians out of the public system, worsening waitlists and service gaps. As a result, patients will face greater out of pocket costs, longer delays, or will be forced into private care they cannot afford.

In short, public money combined with private delivery weakens the public system and increases costs for users, particularly those already waiting.

Patients, communities and health system need a collective voice

Nearly 30 months ago I argued in Otaihanga Second Opinion that Aotearoa’s health system depended on voice for its protection and promotion (21 October 2023):    Importance of voice in health systems.

In that context, I was advocating for the voice of health professionals to be expressed and listened to. However, like the Coalition for Public Health in the 1990s, Kaitiaki Hauora – Together for Public Health broadens this voice further.

Its strength springs from both this broadening and its commendable objectives.

What differentiates the need for this collective voice both in the 1990s and now, is the express privatisation agenda of the National government in the former period and the current National-ACT-NZ First government.

Christopher Luxon’s government is privatising by deliberate design towards making healthcare a tradeable commodity

The Labour led government of the 2000s and its successor National-led government did privatise somewhat, particularly hospital laboratories which has proven to be a clinical and financial disaster.

But this was more due to poor decision-making rather than deliberate design. As it was in the 1990s, today privatisation is being driven by deliberate design.

In other words, as in the 1990s, healthcare is intended to transition towards becoming a commodity rather than a universal public good.

The indestructible, and on the mark, David Galler deserves the final word on this subject from his above-mentioned Listener article:

Our health system belongs to us the people, but it’s design, funding, management and delivery have become increasingly and divisively politicised. If we care about publicly provided healthcare, we need to fight for it.

 

Ian Powell was Executive Director of the Association of Salaried Medical Specialists, the professional union representing senior doctors and dentists in New Zealand, for over 30 years, until December 2019. He is now a health systems, labour market, and political commentator living in the small river estuary community of Otaihanga (the place by the tide). First published at Otaihanga Second Opinion.