Definición del Efecto Tratamiento Promedio (ATE)

The New Zealand Health Strategy (2000)51 _{is strategic public policy in health}52_{. The NZHS}

outlines “health goals and targets... sector performance standards... [and] strategies” (Office of the Minister of Health, n.d., p. 2). It is, primarily, the application of “the Government’s broad objectives for health” (Office of the Minister of Health, n.d., p. 1). These objectives are a composite of the Labour and Alliance perspectives, as outlined in their respective manifestos (see Alliance Party, 2001; New Zealand Labour Party, 1999). According to Office of the Minister of Health (n.d., p. 1), the objectives are to:

a) raise the health and independence of the population and reduce inequalities b) meet the health and disability support needs of local communities

c) ensure more effective use of the available resources

51 _{Henceforth referred to as “the NZHS”.}

52 _{For a critical analysis of the NZHS and its contribution to the refurbishment of the social democratic}

d) increase community involvement in decision-making about health and disability support services

e) have a non-commercial, collaborative and accountable culture in the publicly funded health sector

f) ensure clear accountabilities

These objectives have also been further developed through the principles of the NZHS.

The NZHS contains seven long-term fundamental principles, which “the health sector will uphold – within the money available [sic]” (Ministry of Health, 2000, p. 2). According to the Ministry of Health (2000, p. 7 – numbering added), the principles are:

1) Acknowledging the special relationship between Māori and the Crown under the Treaty of Waitangi

2) Good health and wellbeing for all New Zealanders throughout their lives 3) An improvement in health status of those currently disadvantaged

4) Collaborative health promotion and disease and injury prevention by all sectors

5) Timely and equitable access for all New Zealanders to a comprehensive range of health and disability services, regardless of ability to pay

6) A high-performing system in which people have confidence 7) Active involvement of consumers and communities at all levels

Health policy drivers guide these principles. According to Davis and Ashton (2001, p. 5) health policy has (at least) 15 drivers. The discernable drivers of the NZHS are “health status”, the political climate and establishments, the “public”, user verisimilitude, social and cultural factors, and the dominant social philosophy (Davis & Ashton, 2001, p. 5). The principles and their drivers are operationalised through 16 priority objectives, “five service delivery areas”, seven quality management issues, and three implementation strategies (Ministry of Health, 2000, p. viii).

The priority objectives are short to medium-term priorities and focus on the determinants of health. The selection of these objectives above “10 goals and 61 [other] objectives” (Ministry of Health, 2000, p. vii) was based on the “degree” to which they reflect the NZHS principles and, thus, its drivers (Ministry of Health, 2000, pp. 13-14). The objectives are separated into 13 population-based aims and three focussed specifically on the reduction of inequalities. The objectives involve areas, which can be resolved by the health system alone and others, which require collaborative effort. For example, an objective on the reduction of violence allows opportunities for collaboration with other services, such as the Police. The application of these

objectives is expected to be “evolutionary rather than revolutionary” (Ministry of Health, 2000, p. 14), so that effects on other services can be minimised.

The priority service delivery areas are public and primary health, the reduction of elective surgery delay times, ameliorating the “responsiveness of mental health services”, and increasing accessibility to appropriate health care for rural communities (Ministry of Health, 2000, p. 19). The prioritising of these areas signifies that they “should be considered first if extra funding becomes available” (Ministry of Health, 2000, p. 19). The quality management issues involve “sector-wide” development, “individual rights”, a consultative and co-ordinated approach, information technology and administration, “workforce development”, and appraisal systems (Ministry of Health, 2000, pp. 25-28). The quality, performance, and efficiency of health services are to be of the highest standards, with “achievements rewarded” (Ministry of Health, 2000, p. 26). Management is expected to maintain these standards “within available resources” (Ministry of Health, 2000, p. 25). Thus, the notion of fiscal responsibility, like some other practices employed by previous governments, has been retained by the NZHS. All aspects of the NZHS have been affected, either explicitly or implicitly, by the institutional policies and practices applied during the National and National-New Zealand First Coalition53

Governments. The necessity for a system, which embodies high quality and public confidence, reflects fifteen years of the New Right. Health professionals are now subjected to “real pressures... to perform and to be accountable for their decisions” (Ashton, 2001, p. 123). Health consumers will no longer accept inefficient, ineffective service delivery. Quality health services are expected to meet high “performance” (Ministry of Health, 2000, p. 25) standards and to create “customer satisfaction” (Ministry of Health, 2000, p. 26). Though the aim of the NZHS is to improve “health outcomes”, health providers (such as DHBs) will “still be required to function in a business-like manner” (Ashton, 2001, p. 120). For example, the NZHS is quite specific on the fiscal issue: “budgets are capped and distributed through the population-based funding formula. Thus, “the health sector will need to ensure limited resources are used in the best way possible” (Ministry of Health, 2000, p. 25).

The use of contracts – now termed “funding agreements” – and performance indicators have been retained to ensure “quality standards and delivery expectations” are fulfilled and performance levels are “benchmarked” (Ministry of Health, 2000, p. 26). Chief executives, such as the officer employed by the MidCentral DHB, have had their roles adjusted, but have retained management roles (MidCentral District Health Board employee, personal

communication, September, 2001). Furthermore, the retention of the language of the market, such as “consumer”, suggests a continuation of a liberal health model (Ministry of Health, 2000, p. 26).

Within the NNZF Coalition Agreement (1996, in Ashton, 2001, p. 119), a commitment to “cooperation and collaboration rather than competition” was emphasised – much like the commitment being proposed by the current Coalition Government through the NZHS. However, the NNZF Coalition’s commitment did not result in significant changes within the health sector, particularly after that Coalition’s collapse (see Ashton, 2001). The ongoing effects of this collapse have maintained the market model within the health sector. Nevertheless, this does not mean a return to centralised control is condoned.

A strong element of centralisation seems to underline the NZHS. Central control and planning is reflected in the use of “performance and/or funding agreements” between central government and DHBs (Ministry of Health, 2000, p. viii). The NZHS is very specific about the expectations of DHBs, at least in the short to medium term. Though extensive support is absolutely necessary, especially at the initial stages, the NZHS shows no method for decreasing central authority and increasing community control. A return to an interventionist state is unlikely, given the “political and economic” “transfer costs” of such a change (Myles & Quadagno, 2000, p. 3). However, unless the policymakers and local representatives ensure this “ongoing process” (Ministry of Health, 2000, p. viii) results in relative local autonomy, the result of these health reforms will be little more than a window dressing. It is hoped that the current Government will assist the NZHS in ensuring health sector reform is substantive.