Comment: As political candidates talk about health in the coming weeks, listen for more than promises to reduce waiting-lists.
Most of what makes us sick—and keeps us well—happens outside hospitals. A health system that forgets this will stay overwhelmed and unaffordable.
New Zealand spends more than $30 billion a year on health, yet the basics are still failing: a GP appointment when you need one, an emergency department that isn’t overflowing, timely surgery.
The political response is to focus on those pressure points: waiting lists, targets, faster treatment. That assumes the health system is simply the hospitals, clinics, and medicines that treat us once we are sick.
Consider a child admitted to hospital with a serious chest infection. She is treated well and sent home to the same cold, damp, overcrowded house that made her sick. Months later she is back. The hospital did its job each time. The system failed her, and paid twice.
In 2008, the World Health Organization’s Commission on the Social Determinants of Health concluded that health was largely created where we were born, live, work, and play. In New Zealand, people in the most deprived neighbourhoods die about a decade earlier than those in the least deprived.
The same gradient runs across most health conditions. For example, children in the most deprived areas are about 30 percent more likely to be admitted to hospital for respiratory conditions; 5 to 12-year-olds are hospitalised for preventable dental disease at nearly three times the rate of those in the least deprived areas.
This is not bad luck or individual choice. It reflects the conditions in which people live: housing, income, food, water, work, transport, environment, and whether there is anyone nearby to turn to. Medical care matters when we are ill, but it is only one of many things that decide whether we become ill.
The health system is much wider than healthcare. It includes landlords and councils, schools and employers, marae, churches, local providers, and the shops, parks, playgrounds, and the streets around us. Define it only as the part that treats illness and we will keep paying, at the most expensive point, for problems created everywhere else.
Prevention is not a luxury competing with hospitals for funding; it is the only realistic way to reduce the demand overwhelming them.
Prevention must happen in the places where the conditions that make people sick are found. This is where the people best placed to change these conditions are also found. In the early COVID-19 response, iwi, Māori, and community providers ran testing, vaccination, and outreach, and kept people fed when local food systems failed, meeting needs central agencies could not see. Once resourced, local groups moved quickly because the relationships and trust were already there.
So why don’t we value prevention outside of an emergency? Partly because it pays off slowly, often as illness that never happens. A hip operation can be counted this quarter; the future hospital admission that is prevented by a warm, dry house is not. This sits poorly with three-year political terms, which reward what can be delivered before the next election.
The deeper damage is to local relationships, which take years to build and one restructure to lose. Over four decades we have restructured the health system again and again, while the money and big decisions stay largely where they are. What changes are the people, the priorities, and any certainty about next year’s funding.
Short-term, siloed contracts make it worse: they set local organisations competing for the same small pots of money when prevention depends on them working together. No one can plan long term when the ground keeps shifting.
We have been doing the reverse of what’s needed. Localities—the Healthy Futures (Pae Ora) Act mechanism for bringing community needs and voice into health planning—have been paused until the end of the decade. Without this local voice, and without memory of the past, many communities become invisible to the system meant to serve them.
Go back to the child in the hospital bed. This election, most parties will promise to treat her faster. Few of those promises will stop her coming back. That depends on a warm, dry house, enough income, and local services her whānau know and trust—and that is the health system too.
Judged by its queues, our $30b system needs only more resources and better management. Judged by the demand it absorbs from cold houses, low incomes, and broken relationships, it needs something different: community involvement in identifying local needs and planning services; primary care rewarded for acting on them; long-term funding that enables collective action and real spending authority for community and iwi providers; budgets pooled across sectors; and local relationships resourced and protected.
Much of this is about some of the same money, spent differently. That is what makes it hard: it asks those who hold budgets to share control.
As we countdown to the election, ask candidates whether they understand that local organisations, their knowledge, and trusted relationships, are part of the health system, and whether parties will fund them as prevention rather than cut them as a cost.
And ask whether their commitments will outlast a three-year term. A system that only treats will never be able to treat enough.
This article was originally published on Newsroom.
Anna Matheson is an associate professor in the School of Health at Te Herenga Waka—Victoria University of Wellington.