An analysis of the implementation of health policy in New Zealand 1991-1996

Abstract

In July 1991 Simon Upton, Minister of Health for the National Government released the green and white paper Your Health and the Public Health: a Statement of Government Health Policy. The policy involved considerable restructuring of the health system and was to be implemented within two years. The stated primary objective of the policy was “to secure, for everyone, access to an acceptable level of health care” (Upton 1991: 1 ). This was to be achieved by Government explicitly defining a core of services to which everyone would be entitled. The unstated objective of the policy was to control fiscal risk in health spending. This was to be achieved by targeting Government subsidised health care services only to high users and those on low incomes. Others, the majority, would take financial responsibility for their own health care. It also involved establishing a managed market in the health system to increase efficiency in health service delivery. This was to be achieved by: separating the roles of purchasers and providers; introducing competition between both purchasers and providers; providing choice of purchaser; separating the funding, purchasing and providing of public health services from personal health services; and larger public hospitals becoming commercial enterprises competing with private hospitals and each other for the provision of services. The policy also included integrating the funding of primary and secondary care, and accident-related and non-accident related care; and extending user part charges. This thesis researches the process of implementation of the policy as it was taking place. It analyses the nature of the policy and its implementation strategy, it situates it in an historical and international perspective, focuses on significant areas of the policy during implementation, and analyses the policy changes which have taken place. Though crucial aspects of the policy were not implemented as planned, a substantially changed health system has resulted from the introduction of the policy. I argue that the unstated objective of the policy has been substantially achieved through the introduction of market principles and by shifting responsibility for health care onto individuals. The stated primary objective has not been achieved. There is no explicit definition of the core of services to which everyone was to have access, and for a large section of the population access to Government subsidised health care services has been reduced through targeting and increases in user part-charges. The policy contained flaws which were illuminated during the implementation process and which induced the Government to make changes. The content of the policy and its implementation process were inextricably linked, not separate categories in a linear sequence. I examined the implementation literature, especially that contained within the Top-Down Bottom-Up debate. I argue that this literature is not adequate to explain the implementation of this particular policy. The substantive content of the policy influenced the process of its implementation and the experience of implementation had an important influence on the eventual outcome of the policy.