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Assignment 1
New Zealand is ranked 15th in providing best healthcare services in the world (The World Bank, 2018). This essay briefly outlined the existing framework of the New Zealand healthcare system and the organizations working together to achieve the health goals. Then, the critical analysis of funds distributed and utilized to improve the health sector and services along with the historical aspect of the current health sector, its restructuring, limitations, amendments and developments. This essay also demonstrates a comparison between New Zealand and India’s health sector setup and explained the access barriers to fundamental health services such as doctor, maternity care, dental and prescription drugs for the socioeconomically deprived ethnic groups.

Structure of New Zealand Healthcare System
The Labour-Alliance Coalition government restructures the New Zealand healthcare system in 2000 by implementing New Zealand Health Strategy 2000 (NZ Health Reforms, 2009). The organizational structure of the New Zealand healthcare system consists of a combination of various helping organisations, advisory communities, Ministry of Health, 20 District Health Boards and ACC (Ministry of Health, 2016). These government and non-government organisations work to deliver health services to all through an exchange of funding and accountability. Ministry of Health regulates the fund distribution to District Health Boards to provide or deliver healthcare services in their focus population (Ministry of Health, 2016).

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Critical analysis of Funding system
The main source of funding for New Zealand’s health and disability system is general taxation through Vote Health along with other funding sources such as ACC, other government agencies, local government and private sources i.e. insurances and out-of-pocket payments. The fund distribution is managed by the Ministry of Health that allocates 3/4th funds to DHBs. The national services such as disability support services, Public health, specific screening programs, Mental health, Well Child and primary maternity services, Maori health etc is funded with 19% of public funds and rest 1% is utilized for maintaining and running the Ministry (Ministry of Health, 2016). This distribution is further explained by Ministry of Health (2002) in Health expenditure trends in New Zealand 1990–2001: 60% of public funds in primary care and 25% in dental care. In addition, Primary Healthcare Strategy is implemented to improve primary healthcare services provided by GPs, nurses and other health professionals under community-based primary healthcare. The population-based funding formula is based on demographic details of enrolled people (NZ Health Reforms, 2009). PHOs are funded to provide essential primary healthcare services including preventive services, for maintaining population health and mitigating health disparities among people. In this, first contact service is free or low for all enrollees. This funding system is effective in reducing the cost but it is incapable of eliminating costs for such services (Foley, 2018). The fee-for-service and free hospital services are proven to increase disparities and are not effective (Cumming, 2011). They widened the gap of services delivery due to the communication barriers or exchange of little or no information among different health providers (Cumming, 2011). Croxson (2009) stated that this initiative challenges the traditional business modal of general practice and creates tension between universal and targeted approaches. The outcomes of this change are evident as a deduction in fees and rise in consultation rates and expansion of new health services (Cumming & Mays, 2011).

Currently, DHBs and PHC are working in an alliance (Lovelock et. al, 2014) to deliver health services closer to people’s home (Ryall, 2007). The drawback of this alliance is that more funding is invested in primary care and less in left for hospitals (secondary and tertiary health sector).

Moreover, Keene and Lyndon (2016) pointed out that restructuring of health funding system is not required, instead, the allocation of sufficient funds for fulfilling the needs of the population is a necessity. New Zealand health survey revealed that statistics of unmet needs of primary healthcare, in which 29% of adults and 24% of children are experiencing services deficiencies (Ministry of Health, 2016). The shortcomings of primary healthcare strategy are; lack of choice of a consumer over providers and limited services such as chronic condition (Finlay, 2012). Even, Access and Interim capitation structure focused on high-need population and failed to access disparities for indigenous people to primary care (Langton ; Jennifer, 2008).

Apart from this, co-payments to GPs and increasing subsidies for GP visits- Care plus, VLCA, HUHC, and Community services cards are introduced (Ministry of Health, 2015). Along with PHC, ACC covered up for long queues in the public system by purchasing health services from the private sector and regulated the recovery process of an individual (Pollack, 2007).

Apparently, an economist Bill Rosenberg (2016), Council of Trade Union analysed last year’s budget of Vote Health and found that there is 1.2 billion downfall in health sector funding in 2016/2017 by core government as compared to last 7 years and it is rising annually. Another finding by an economist Professor Michael Cooper showed that only 7% of GDP is spent in the health sector and in the coming year, health funding will increases eventually due to advanced medical services (Keene & Lyndon, 2016).

Nicholls (2017) concluded that the New Zealand health system is under-funded as its funding is fallen as compared to OECD countries. So, an adequate funding is needed.

Brief analysis of history of New Zealand Health Reforms
New Zealand health care system experienced a series of structural transformations even before 1983. The health care system had two aspects; public and private prior to 1983. In 1974, ACC was introduced. The increased health expenses and health disparities forced the government to change the healthcare setup.

New Zealand health sector reformed four times in last 20 years and moved from curative to preventive health services. The first reform was from 1983 to 1992: decentralization of power of the healthcare department to 14 Area Health Boards was done. AHBs had funded according to population-based formula and more focus of this reform was management and purchase of health services. This reform was aimed at increasing provider choice for patients and improving public hospitals services and reducing waiting time by setting up competition between providers through quasi-market (Gauld, 2009). This was highly criticized by health professionals and the public as it turned out unexpected and was financially and politically expenses (Ashton, Mays & Devlin, 2005). The second reform came into play in 1993-1997: four regional health authorities were formed that bought health services from competitive health market providers. The strategy was to stop resource allocation disparities, buy services from best providers, primary and secondary services to accommodate under the same purchaser and prioritizing decision-making under extensive national priorities. Additionally, the Department of Health became the Ministry of Health and public hospitals services separated from purchasing functions. The most evident shortcomings of this reform were an implementation cost, lack of service definition and difficulty in contracting. Moreover, an increase in waiting lists and timing for operations were seen (Crown Company Monitoring Advisory Unit, 1996) and poor quality of care due to the reduction in nursing workforce (McCloskey & Diers, 2005). Pharmac was developed and PHC services were made more accessible to the public.
In third reform (1998-2001), Crown Health Enterprises renamed as Hospital and Health Services and the centralization of health funding into Health Funding Authority took place. Hospitals made less commercial by introducing community representatives on hospital boards. This reform abolished the norm of quasi-market competition. There was an absence of future vision, leadership and community input and more focus was on improving treatment services by ignoring community health (NZ Labour Party, 1999). The last or current reform (2001-present) is marked as a formation of 21 District Health Boards. The provision of health funding through general taxation was fully accepted. Ministry of Health manages the healthcare system. This reduces population-based health disparities and accessibility issues. This reform’s arrangements were similar to the reform of 1993 (Devlin, Maynard, ; Mays, 2001). The significant change is a formation of Primary Health Organisations and DHBs providing public hospitals and personal health services.

However, even after the implementation of this reform, some minor restructuring took place such as an introduction of New Zealand Health Strategy and New Zealand Disability Strategy in 2008 (Ministry Of Health, 2001). Till today, the reform is working well.

Comparison between Health System of New Zealand and India
The country’s government is responsible for the delivery of best and equitable healthcare services to its citizens. New Zealand’s healthcare system is ranked in top 10 countries providing best healthcare services in the world (The World Bank, 2018). It is supported mostly by the government (77% approximately)(WHO, 2008-2009), whereas the private healthcare sector dominates in India (Berman, 2010).

In New Zealand, the healthcare system is led by the Ministry of Health and its 20 District Health offices and Boards (Ministry of Health, 2016). The funds for healthcare services are collected through general taxation from the public (Cumming, 2011). The New Zealand government spend 9.34% of GDP on heath in 2015 (The World Bank, 2018). Almost every citizen is covered under health insurance except people of low socio-economic status. The funds for healthcare services are delivered on a population-based formula. The healthcare services in New Zealand is divided into a primary, secondary and tertiary sector, where primary services are delivered at Primary Health Centres and secondary and tertiary sectors services come under hospitals (Ministry of Health, 2016). The mental and disability support is provided by some non-government organisations (NZ Parliamentary Library, 2009). The GPs visits are subsidized by Community Service Cards and for children under 6 (Ministry of Health, 2016). High tech curative services are free in government setup. In addition, the Accident Compensation Corporation also helps DHBs in maintaining the health of people by treating them in case of accidents and injuries (ACC, 2010). Some people also prefer CAM (Complementary Alternative Medicine) or traditional Maori medicines and homeopathy because of their ingenuous nature and with little or no side-effects (Nicholson, 2006; Holt ; Gilbey, 2009).

On contrary, the Indian government spends only 1% of GDP on health (WHO, 2014) which increased to 3.89% in 2015 (The World Bank, 2018). Indians pay healthcare expenses out of their own pockets (Berman, 2010) which are estimated to be 80% and the government’s contribution is 20% (Government of India, 2004). The health sector in India is divided at three levels: Central, State and Local. The private providers are contacted first for primary care due to the belief that they provide a better quality of services (WHO, 2014). Apart from this, the practice of seven indigenous system of healthcare such as Ayurveda, Unani, Yoga, Siddha, Sowa-rigpa, Naturopathy, and Homeopathy is more prevalent in India for providing primary care (Planning Commission, 2012). This is because of a failed public sector that is underfunded, undersupplied and understaffed (Ministry of Health and Family Welfare, 2015). Moreover, the private sector mostly delivers secondary and tertiary services and not the preventive healthcare. So, funding in the public sector is increased and the National Rural Health Mission is introduced for improving primary care (NRHM, 2005). It is government-sponsored insurance that covers hospital care for poor people at empanelled hospitals (Forgia & Nagpal, 2012). Also, some health insurance schemes namely Arogya Bhagya, Yeshasvini, Arogya Bhadrata are in action (Ramani & Mavalankar, 2006). Nevertheless, government offered free health services only for population below poverty line that showed inequitable access of healthcare services to the people. Even in public hospitals, treatments through advanced technologies are unaffordable. The employers provide limited health benefits to their employees at the workplace. The shortage of healthcare services in rural areas is a troublesome issue faced by Indian health sector (Ramani & Mavalankar, 2006).

Both the healthcare systems have their own pros and cons. The provision of healthcare services to all may be a positive aspect of New Zealand healthcare system as its enabling citizens with an equal opportunity of staying healthy but for achieving this goal government needs to invest more revenues in the healthcare system which will affect the development of other sectors in country. The less health expenditure of Indian government may be considered as less burden on nation’s economy and other sectors can flourish but deteriorating health and inaccessibility of people to better treatment and services strangulate the overall development of a nation.

Hence, the New Zealand healthcare system is managed by the Ministry of Health and 20 District Health Boards for the proper delivery of health services to all. A large amount of public funds goes to DHBs to provide primary and preventive healthcare services in a subsidized manner. In history to present day, the health sector is influenced by political authorities and ruling government and it encountered drastic changes from the beginning. Indeed, the New Zealand health system is far better than India’s health system, though it has its own flaws and shortcomings.

Critical discussion of access barriers to Ethnic Identity
An overall improvement in the health status of New Zealanders might be seen over time but, health inequalities are still prevalent in the country. The indigenous people (Maori and Pacific) are worst hit by these disparities. The health disparities between indigenous and other population are based on genetic and non-genetic factors whereas, genetics are related to some specific conditions and non-genetic includes; socio-economic, lifestyle, access to healthcare, discrimination and racism. There are high premature and morbidity and mortality rates among indigenous people with soaring deprivation as compared to other population in New Zealand (Eachus, Williams & Chan, 1996). To illustrate, Smith and Pearce (1984) examined data from 1974 to 1978, and reported that male mortality rates differences attributable to approximately 20% to differences in socioeconomic status, whereas 15% was linked to cigarette smoking (15%); alcohol consumption (10%); obesity (5%); and accidents (17%).
The most important factors behind these disparities are the financial barriers, structural barriers and personal barriers to access Primary health services.

The financial barriers define as an individual unable to pay the doctor’s visit cost. The root causes of this are poor or low income. The unemployment and less paid jobs are factors associated with poor health outcomes (Keefe et al., 2002; Blakely et al., 2003). For instance, the highly paid New Zealand males had an increase in life expectancy (5.1 years) compared with low -income males (3.5 years) (New Zealand Ministry of Health 2005). These are further related to the low literacy rate among indigenous people. Even, they encounter discrimination at workplaces (Sutherland ; Alexander 2002; Alexander et al., 2003). The detailed investigation of the low-income status of indigenous people revealed that people living in adverse conditions are more likely to get ill in a poor housing (Howden-Chapman ; Carroll, 2004).

The structural barriers include lack of primary care providers, discrimination by the healthcare professional of other ethnic groups, less cultural staff and cultural incompetence. One survey, studied by Harris, Stanley ; Cormack (2018) showed that Asians experienced 13-15% racism, whereas Maori and Pacific people reported only 8-10% racism. Additionally, an increase in a number of Maori health providers was evident in a decade (1993-2004) from 13 to 240, but they are still facing difficulties in providing healthcare services (Kiro, 2000).

Finally, the personal barrier demonstrates the language barrier in the health system (Anderson ; Armstead, 1995).
Subsequently, the most important factor behind these disparities is the financial barrier to access Primary health services. Primary healthcare is only limited to access to general practitioner but financial barrier also includes visits to a dentist, prescription drugs and maternity services. Primary health care is funded only 60% by government and rest of expenses patients pay out of their pockets. Many patients defer their visit to GPs, dentist and maternity care and do not collect their prescribed drugs due to the treatment cost leading to poor health. Furthermore, to reduce treatment cost and improve access to Primary Health Care Strategy (King, 2001) was formed that grouped all health professionals under Primary Health Organization. The patients enrolled in PHOs benefitted from subsidized primary health services. The socioeconomically deprived groups such as Maori and Pacific are enrolled under Access primary care, whereas middle-income people enrolled under Interim primary care. As a result, GP’s visit cost from $50 to $25 or less and few services are provided free of cost (Ministry of Health, 2004).

A small fraction (25%) of public funding used in dental care expenditure and that also focussed on child and adolescent dental care (Birch & Anderson, 2005). The free dental care is provided till the age of 12 through school-based dental therapists. On the other hand, adolescents firstly get registered under private dentist to enjoy the subsidized dental care, whereas a specific group of adults have access to free care only in hospital-based dental clinics and the rest of people pay full treatment cost to a dentist (Thompson, 2001).

The maternity care services are also government funded under Lead Maternity Care (LMC). These services are provided by a midwife instead of GPs. Every pregnant woman needs to register under LMC to get antenatal and post-antenatal services (Priday & McAra-Couper, 2016). There are certain examples of health disparities in maternity care. In New Zealand, a large number of Maori and Pacific woman give birth in low socioeconomic areas (PMMRC, 2012). Regarding this, Bartholomew (2010) found that 4.6% of Maori and 5.2% Pacific Island women do not have access to LMC for maternity services for maternity care. They received antennal care from DHBs but no post-delivery care. Apart from this, cultural barriers are the causes of less registration of indigenous women in LMC and location of people in rural and deprived areas. The maternity care’s accessibility and effectiveness for indigenous people are influenced by cultural appropriateness (Smylie ; Adomako, 2009).

Furthermore, the subsidies on pharmaceutical items also increased. To illustrate, every item’s price reduced from $15 to $3 for all Access and Interim PHOs enrolled patients (Ministry of Health, 2007) though this benefit is applicable to people of 65 or above age group in Interim PHO. PHARMAC is responsible for deciding subsidies on prescription drugs.

So, the data from the study named SOFIE (Survey of Family, Income and Employment) was conducted to analyse cost barriers in access to primary care. It was the largest and longest survey ever conducted in New Zealand for the duration of 8 years. The total participants were 22,000 out of which 18,320 responded to the survey. The method used was 20 minutes long questionnaires. The people from different ethnic groups and life status were involved. The results showed that overall 15.5% defer their visit to GP, 22.8% to a dentist and 6.4% defer buying prescription drugs once in the year due to cost barrier.

However, the percentage of Maori people postponing the visit to GP, dentist and purchasing prescription drugs was 23.8%, 33.2% and 13.6% respectively. Similarly, the Pacific population had deferring percentage of 21.7%, 30.7% and 15.4%. In contrast to this, Asians were more conscious about their health and had a minimum percentage of visit delays (10.1%, 19.4%, 3.3%). The most evident part is that more defers a visit to the dentist as it follows the fee-for-service rule (Jatrana & Crampton, 2009).

In short, indigenous people encounters more barriers like financial, structural and personal to access primary care and these barriers drastically affected the health outcomes of Maori, Pacific and middle-income individuals. The implementation of heavy subsidies in Primary care is not sufficient to eliminate cost barriers and increased access to services but upraising of the socioeconomic status of deprived groups is also equally important. It is also notable that, health outcomes depend on utilization of these services by people.

To summarise, Ministry of Heath controls the working of New Zealand healthcare system along with other organisations. DHBs are heavily funded for providing accessible primary healthcare services to the public. The health reforms showed drastic restructuring from the beginning to the present and many positive amendments took place that makes New Zealand health sector better from India. Although the government tried to improve the approachability of health services for all group of people, yet the access barriers are still prevalent among the indigenous population.

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