Assessment of unmet secondary elective healthcare need—itself in need of acute care in Aotearoa New Zealand
View Article PDF
Unmet need in healthcare is a global issue, not least in Aotearoa New Zealand. Whether the health needs of a population are met—or not—is a critical indicator of the extent to which a health system provides comprehensive and equitable care. Although the health workforce may be aware of unmet healthcare needs on a local day-to-day basis, the issue for policy makers is deciding how best to allocate scarce national or regional resources. A central database that makes use of internationally standardised measures of unmet health need is vital for the development and implementation of health policy, despite the discomfort that arises when such a database inevitably exposes health system weaknesses and resource constraints. Without the use of standardised measures of unmet need, estimates are biased, international comparisons are flawed, and robust policy development and implementation is compromised. Improvements in health not only have enormous social value, they also lead to economic benefits for society.[[1–8]] Access to healthcare is a recognised determinant of health;[[9]] hence a strategy to make universal health coverage a worldwide objective (SDG Target 3.8) has been adopted by the United Nations.[[10]] Despite this, even in countries with state-funded health systems, there is evidence of unmet need and inequitable access to healthcare.[[11–13]]
In Aotearoa, although unmet primary healthcare need (UPHN) has been extensively and repeatedly estimated through the New Zealand Health Survey (NZHS), unmet secondary elective healthcare need (USEHN) has not. In this context, “elective” is to be distinguished from “acute or emergency” and characterises those to be admitted for care from a waiting list. Given that neither governments nor the New Zealand Ministry of Health have ever committed to the accurate assessment of USEHN, it is reasonable to wonder whether they really wish to know its true extent.
There have always been unacceptable ethnic and other socio-economic inequities in healthcare access and outcomes and these require urgent attention. USEHN, specifically, is a cause of unnecessary suffering, disability and death, and is also a modifiable cause of health inequalities.[[14,15]] In our 2017 pilot survey of USEHN, in which 29% of respondents reported UPHN, 9% reported USEHN that had been identified by a health professional.[[16]] Aotearoa has no accurate estimate of the prevalence of USEHN among Māori, so we lack basic understanding of the extent to which USEHN contributes to health inequalities between Māori and non-Māori.
Inclusion of appropriate questions on USEHN in the NZHS that can be benchmarked internationally would take advantage of the methods currently used in the national survey to obtain a representative sample[[17]]—methods similar to those also used in the New Zealand National Mental Health Survey: Te Rau Hinengaro.[[18]] How well our health system is meeting the needs of an increasingly diverse population requires a representative sample across ethnic, social, and regional sub-populations. Inclusion of USEHN in the NZHS would also bring us into line with the many countries that routinely undertake relevant population surveys, countries that recognise that unmet need is an essential indicator of the effectiveness of healthcare systems.[[19–21]]
Health systems evolve, incrementally or as a result of structural reform. The New Zealand Health Reforms of the 1990s were based on neoliberal philosophy of a market for health with austerity budgeting. Hardy remnants of this failed philosophy remain embedded in the health system;[[22]] scant attention is still paid to the European and US studies that show investment in healthcare pays large fiscal dividends.[[1,2,7,23]] Prior to the Health Reforms of the 1990s, there were no procedural or structural obstructions to outpatient assessment and admission to hospital waiting lists which, therefore, gave at least a gross indication of the performance of the hospital systems and the level of USEHN. The Health Reforms of the 1990s included the introduction of clinical guidelines and movement from waiting lists to maximal waiting times. These and other barriers to access have left us with no barometers of the level of USEHN.
Central to the current Aotearoa health reforms is the aim of addressing inequalities, particularly for Māori, as well as ensuring improved access to health services, especially for those currently not well served by the system. To achieve these aims, the functions of the disestablished district health boards have been merged into Te Whatu Ora – Health New Zealand, a centralised model to provide “a simpler and more coordinated health system” (https://www.tewhatuora.govt.nz/) and a separate Te Aka Whai Ora – Māori Health Authority. Robust data, including those that cover both UPHN and USHN, will be essential to assess whether or not these aims of the current reforms are achieved.
Regular national surveys of USEHN are done in many countries.[[16]] The questions used have been validated in massive surveys and are still undergoing refinement.[[24,25]] Aotearoa New Zealand needs to adopt these tools to allow international benchmarking. The needed survey of USEHN must be done as part of the New Zealand Health Survey; they have the relevant expertise and would ensure a far more cost-effective approach than establishing a de novo study. As a result of our pilot study, we believe that there needs to be an initial broad survey of all aspects of USEHN, including Māori oversampling to assess regional and other fine details of disparities, followed by a focus on particular areas of USEHN as a core part of subsequent NZHSs.
Routine assessment of both PHN and SHN in the NZHS will be critical to monitor how well the health system is meeting health needs across the Aotearoa New Zealand population and to establish whether the current reforms and future evolution of the New Zealand health system achieve desired outcomes. Now, more than ever, with these health reforms underway with core goals of improving access and equity, it is time to act to properly measure unmet need. Without this, we will continue to live and work in a country that fails to understand and respond to the needs and suffering of our most poorly served.
Summary
Abstract
Aim
Method
Results
Conclusion
Author Information
Acknowledgements
Correspondence
Correspondence Email
Competing Interests
1) Bhattacharya J, Lakdawalla DN. The Labor Market Value of Health Improvements. Forum Health Econ Policy 2006;9(2).
2) Bloom DE, Canning D, Sevilla J. The Effect of Health on Economic Growth: A Production Function Approach. World Dev 2004;32(1):1-13.
3) Gostin LO, Boufford JI, Martinez RM. The Future Of The Public's Health: Vision, Values, And Strategies. Health Affairs 2004;23(4):96-107.
4) Mirvis DM, Chang CF, Cosby A. Health as an economic engine: evidence for the importance of health in economic development. J Health Hum Serv Adn 2008;31(1):30-57.
5) Murphy K, Topel R. Diminishing returns? The costs and benefits of improving health. Perspect Biol Med 2003;46(3 Suppl):S108-28.
6) New Zealand Medical Association. NZMA Position Statement: Health as an investment. https://assets-global. website-files.com/5e332a62c703f653182faf47/5e332a62c703f657212fc559_Health-as-an-investment_FINAL.pdf: New Zealand Medical Association, 2017.
7) Suhrcke M, McKee M, Stuckler D, et al. The contribution of health to the economy in the European Union. Public Health 2006;120(11):994-1001.
8) Reeves A, Basu S, McKee M, et al. Does investment in the health sector promote or inhibit economic growth? Global Health 2013;9(1):43.
9) Dahlgren G, Whitehead M. European strategies for tackling social inequities in health: Levelling up Part 2. https://www.euro.who.int/__data/assets/pdf_file/0018/103824/E89384.pdf: WHO Regional Office for Europe, 2006.
10) UN General Assembly. Sixty-seventh session. Agenda item 123: Global health and foreign policy. https://ncdalliance.org/sites/default/files/resource_files/Global%20Health%20and%20Foreign%20Policy%20resolution%202012_67th%20GA.pdf: United Nations, 2012.
11) GBD 2015 Healthcare Access and Quality Collaborators. Healthcare Access and Quality Index based on mortality from causes amenable to personal health care in 195 countries and territories, 1990–2015: a novel analysis from the Global Burden of Disease Study 2015. Lancet 2017;390(10091):231-66.
12) Cylus J, Papanicolas I. An analysis of perceived access to health care in Europe: How universal is universal coverage? Health Policy 2015;119(9):1133-44.
13) Rodney AM, Hill PS. Achieving equity within universal health coverage: a narrative review of progress and resources for measuring success. Int J Equity Health 2014;13(1):72.
14) Keene L, Bagshaw P, Nicholls MG, et al. Funding New Zealand's public healthcare system: time for an honest appraisal and public debate. N Z Med J 2016;129(1435):10-20.
15) Tobias M, Yeh LC. How much does health care contribute to health gain and to health inequality? Trends in amenable mortality in New Zealand 1981–2004. Aust NZ J Publ Heal 2009;33(1):70-8.
16) Bagshaw P, Bagshaw S, Frampton C, et al. Pilot study of methods for assessing unmet secondary health care need in New Zealand. N Z Med J 2017;130(1452):23-38.
17) Ministry of Health. Metholodology Report 2015/16: New Zealand Health Survey. Wellington: Ministry of Health, 2016.
18) Wells JE, Oakley Browne MA, Scott KM, et al. Te Rau Hinengaro: the New Zealand Mental Health Survey: overview of methods and findings. Aust NZ J Psychiat 2006;40(10):835-44.
19) Gauld R, Raymont A, Bagshaw PF, et al. The importance of measuring unmet healthcare needs. N Z Med J 2014;127(1404):63-7.
20) Reeves A, McKee M, Mackenbach J, et al. Public pensions and unmet medical need among older people: cross-national analysis of 16 European countries, 2004-2010. J Epidemiol Community Health 2017;71(2):174-80.
21) Fjaer EL, Stornes P, Borisova LV, et al. Subjective perceptions of unmet need for health care in Europe among social groups: Findings from the European social survey (2014) special module on the social determinants of health. Eur J Public Health 2017;27(suppl_1):82-9.
22) Barnett P, Bagshaw P. Neoliberalism: what it is, how it affects health and what to do about it. N Z Med J 2020;133(1512):76-84.
23) Masters R, Anwar E, Collins B, et al. Return on investment of public health interventions: a systematic review. J Epidemiol Community Health 2017;71(8):827-34.
24) Smith S, Connolly S. Re-thinking unmet need for health care: introducing a dynamic perspective. Health Econ Policy Law 2020;15(4):440-57.
25) Allan I, Ammi M. Evolution of the determinants of unmet health care needs in a universal health care system: Canada, 2001-2014. Health Econ Policy Law 2021;16(4):400-23.
For the PDF of this article,
contact nzmj@nzma.org.nz
Assessment of unmet secondary elective healthcare need—itself in need of acute care in Aotearoa New Zealand
View Article PDF
Unmet need in healthcare is a global issue, not least in Aotearoa New Zealand. Whether the health needs of a population are met—or not—is a critical indicator of the extent to which a health system provides comprehensive and equitable care. Although the health workforce may be aware of unmet healthcare needs on a local day-to-day basis, the issue for policy makers is deciding how best to allocate scarce national or regional resources. A central database that makes use of internationally standardised measures of unmet health need is vital for the development and implementation of health policy, despite the discomfort that arises when such a database inevitably exposes health system weaknesses and resource constraints. Without the use of standardised measures of unmet need, estimates are biased, international comparisons are flawed, and robust policy development and implementation is compromised. Improvements in health not only have enormous social value, they also lead to economic benefits for society.[[1–8]] Access to healthcare is a recognised determinant of health;[[9]] hence a strategy to make universal health coverage a worldwide objective (SDG Target 3.8) has been adopted by the United Nations.[[10]] Despite this, even in countries with state-funded health systems, there is evidence of unmet need and inequitable access to healthcare.[[11–13]]
In Aotearoa, although unmet primary healthcare need (UPHN) has been extensively and repeatedly estimated through the New Zealand Health Survey (NZHS), unmet secondary elective healthcare need (USEHN) has not. In this context, “elective” is to be distinguished from “acute or emergency” and characterises those to be admitted for care from a waiting list. Given that neither governments nor the New Zealand Ministry of Health have ever committed to the accurate assessment of USEHN, it is reasonable to wonder whether they really wish to know its true extent.
There have always been unacceptable ethnic and other socio-economic inequities in healthcare access and outcomes and these require urgent attention. USEHN, specifically, is a cause of unnecessary suffering, disability and death, and is also a modifiable cause of health inequalities.[[14,15]] In our 2017 pilot survey of USEHN, in which 29% of respondents reported UPHN, 9% reported USEHN that had been identified by a health professional.[[16]] Aotearoa has no accurate estimate of the prevalence of USEHN among Māori, so we lack basic understanding of the extent to which USEHN contributes to health inequalities between Māori and non-Māori.
Inclusion of appropriate questions on USEHN in the NZHS that can be benchmarked internationally would take advantage of the methods currently used in the national survey to obtain a representative sample[[17]]—methods similar to those also used in the New Zealand National Mental Health Survey: Te Rau Hinengaro.[[18]] How well our health system is meeting the needs of an increasingly diverse population requires a representative sample across ethnic, social, and regional sub-populations. Inclusion of USEHN in the NZHS would also bring us into line with the many countries that routinely undertake relevant population surveys, countries that recognise that unmet need is an essential indicator of the effectiveness of healthcare systems.[[19–21]]
Health systems evolve, incrementally or as a result of structural reform. The New Zealand Health Reforms of the 1990s were based on neoliberal philosophy of a market for health with austerity budgeting. Hardy remnants of this failed philosophy remain embedded in the health system;[[22]] scant attention is still paid to the European and US studies that show investment in healthcare pays large fiscal dividends.[[1,2,7,23]] Prior to the Health Reforms of the 1990s, there were no procedural or structural obstructions to outpatient assessment and admission to hospital waiting lists which, therefore, gave at least a gross indication of the performance of the hospital systems and the level of USEHN. The Health Reforms of the 1990s included the introduction of clinical guidelines and movement from waiting lists to maximal waiting times. These and other barriers to access have left us with no barometers of the level of USEHN.
Central to the current Aotearoa health reforms is the aim of addressing inequalities, particularly for Māori, as well as ensuring improved access to health services, especially for those currently not well served by the system. To achieve these aims, the functions of the disestablished district health boards have been merged into Te Whatu Ora – Health New Zealand, a centralised model to provide “a simpler and more coordinated health system” (https://www.tewhatuora.govt.nz/) and a separate Te Aka Whai Ora – Māori Health Authority. Robust data, including those that cover both UPHN and USHN, will be essential to assess whether or not these aims of the current reforms are achieved.
Regular national surveys of USEHN are done in many countries.[[16]] The questions used have been validated in massive surveys and are still undergoing refinement.[[24,25]] Aotearoa New Zealand needs to adopt these tools to allow international benchmarking. The needed survey of USEHN must be done as part of the New Zealand Health Survey; they have the relevant expertise and would ensure a far more cost-effective approach than establishing a de novo study. As a result of our pilot study, we believe that there needs to be an initial broad survey of all aspects of USEHN, including Māori oversampling to assess regional and other fine details of disparities, followed by a focus on particular areas of USEHN as a core part of subsequent NZHSs.
Routine assessment of both PHN and SHN in the NZHS will be critical to monitor how well the health system is meeting health needs across the Aotearoa New Zealand population and to establish whether the current reforms and future evolution of the New Zealand health system achieve desired outcomes. Now, more than ever, with these health reforms underway with core goals of improving access and equity, it is time to act to properly measure unmet need. Without this, we will continue to live and work in a country that fails to understand and respond to the needs and suffering of our most poorly served.
Summary
Abstract
Aim
Method
Results
Conclusion
Author Information
Acknowledgements
Correspondence
Correspondence Email
Competing Interests
1) Bhattacharya J, Lakdawalla DN. The Labor Market Value of Health Improvements. Forum Health Econ Policy 2006;9(2).
2) Bloom DE, Canning D, Sevilla J. The Effect of Health on Economic Growth: A Production Function Approach. World Dev 2004;32(1):1-13.
3) Gostin LO, Boufford JI, Martinez RM. The Future Of The Public's Health: Vision, Values, And Strategies. Health Affairs 2004;23(4):96-107.
4) Mirvis DM, Chang CF, Cosby A. Health as an economic engine: evidence for the importance of health in economic development. J Health Hum Serv Adn 2008;31(1):30-57.
5) Murphy K, Topel R. Diminishing returns? The costs and benefits of improving health. Perspect Biol Med 2003;46(3 Suppl):S108-28.
6) New Zealand Medical Association. NZMA Position Statement: Health as an investment. https://assets-global. website-files.com/5e332a62c703f653182faf47/5e332a62c703f657212fc559_Health-as-an-investment_FINAL.pdf: New Zealand Medical Association, 2017.
7) Suhrcke M, McKee M, Stuckler D, et al. The contribution of health to the economy in the European Union. Public Health 2006;120(11):994-1001.
8) Reeves A, Basu S, McKee M, et al. Does investment in the health sector promote or inhibit economic growth? Global Health 2013;9(1):43.
9) Dahlgren G, Whitehead M. European strategies for tackling social inequities in health: Levelling up Part 2. https://www.euro.who.int/__data/assets/pdf_file/0018/103824/E89384.pdf: WHO Regional Office for Europe, 2006.
10) UN General Assembly. Sixty-seventh session. Agenda item 123: Global health and foreign policy. https://ncdalliance.org/sites/default/files/resource_files/Global%20Health%20and%20Foreign%20Policy%20resolution%202012_67th%20GA.pdf: United Nations, 2012.
11) GBD 2015 Healthcare Access and Quality Collaborators. Healthcare Access and Quality Index based on mortality from causes amenable to personal health care in 195 countries and territories, 1990–2015: a novel analysis from the Global Burden of Disease Study 2015. Lancet 2017;390(10091):231-66.
12) Cylus J, Papanicolas I. An analysis of perceived access to health care in Europe: How universal is universal coverage? Health Policy 2015;119(9):1133-44.
13) Rodney AM, Hill PS. Achieving equity within universal health coverage: a narrative review of progress and resources for measuring success. Int J Equity Health 2014;13(1):72.
14) Keene L, Bagshaw P, Nicholls MG, et al. Funding New Zealand's public healthcare system: time for an honest appraisal and public debate. N Z Med J 2016;129(1435):10-20.
15) Tobias M, Yeh LC. How much does health care contribute to health gain and to health inequality? Trends in amenable mortality in New Zealand 1981–2004. Aust NZ J Publ Heal 2009;33(1):70-8.
16) Bagshaw P, Bagshaw S, Frampton C, et al. Pilot study of methods for assessing unmet secondary health care need in New Zealand. N Z Med J 2017;130(1452):23-38.
17) Ministry of Health. Metholodology Report 2015/16: New Zealand Health Survey. Wellington: Ministry of Health, 2016.
18) Wells JE, Oakley Browne MA, Scott KM, et al. Te Rau Hinengaro: the New Zealand Mental Health Survey: overview of methods and findings. Aust NZ J Psychiat 2006;40(10):835-44.
19) Gauld R, Raymont A, Bagshaw PF, et al. The importance of measuring unmet healthcare needs. N Z Med J 2014;127(1404):63-7.
20) Reeves A, McKee M, Mackenbach J, et al. Public pensions and unmet medical need among older people: cross-national analysis of 16 European countries, 2004-2010. J Epidemiol Community Health 2017;71(2):174-80.
21) Fjaer EL, Stornes P, Borisova LV, et al. Subjective perceptions of unmet need for health care in Europe among social groups: Findings from the European social survey (2014) special module on the social determinants of health. Eur J Public Health 2017;27(suppl_1):82-9.
22) Barnett P, Bagshaw P. Neoliberalism: what it is, how it affects health and what to do about it. N Z Med J 2020;133(1512):76-84.
23) Masters R, Anwar E, Collins B, et al. Return on investment of public health interventions: a systematic review. J Epidemiol Community Health 2017;71(8):827-34.
24) Smith S, Connolly S. Re-thinking unmet need for health care: introducing a dynamic perspective. Health Econ Policy Law 2020;15(4):440-57.
25) Allan I, Ammi M. Evolution of the determinants of unmet health care needs in a universal health care system: Canada, 2001-2014. Health Econ Policy Law 2021;16(4):400-23.
For the PDF of this article,
contact nzmj@nzma.org.nz
Assessment of unmet secondary elective healthcare need—itself in need of acute care in Aotearoa New Zealand
View Article PDF
Unmet need in healthcare is a global issue, not least in Aotearoa New Zealand. Whether the health needs of a population are met—or not—is a critical indicator of the extent to which a health system provides comprehensive and equitable care. Although the health workforce may be aware of unmet healthcare needs on a local day-to-day basis, the issue for policy makers is deciding how best to allocate scarce national or regional resources. A central database that makes use of internationally standardised measures of unmet health need is vital for the development and implementation of health policy, despite the discomfort that arises when such a database inevitably exposes health system weaknesses and resource constraints. Without the use of standardised measures of unmet need, estimates are biased, international comparisons are flawed, and robust policy development and implementation is compromised. Improvements in health not only have enormous social value, they also lead to economic benefits for society.[[1–8]] Access to healthcare is a recognised determinant of health;[[9]] hence a strategy to make universal health coverage a worldwide objective (SDG Target 3.8) has been adopted by the United Nations.[[10]] Despite this, even in countries with state-funded health systems, there is evidence of unmet need and inequitable access to healthcare.[[11–13]]
In Aotearoa, although unmet primary healthcare need (UPHN) has been extensively and repeatedly estimated through the New Zealand Health Survey (NZHS), unmet secondary elective healthcare need (USEHN) has not. In this context, “elective” is to be distinguished from “acute or emergency” and characterises those to be admitted for care from a waiting list. Given that neither governments nor the New Zealand Ministry of Health have ever committed to the accurate assessment of USEHN, it is reasonable to wonder whether they really wish to know its true extent.
There have always been unacceptable ethnic and other socio-economic inequities in healthcare access and outcomes and these require urgent attention. USEHN, specifically, is a cause of unnecessary suffering, disability and death, and is also a modifiable cause of health inequalities.[[14,15]] In our 2017 pilot survey of USEHN, in which 29% of respondents reported UPHN, 9% reported USEHN that had been identified by a health professional.[[16]] Aotearoa has no accurate estimate of the prevalence of USEHN among Māori, so we lack basic understanding of the extent to which USEHN contributes to health inequalities between Māori and non-Māori.
Inclusion of appropriate questions on USEHN in the NZHS that can be benchmarked internationally would take advantage of the methods currently used in the national survey to obtain a representative sample[[17]]—methods similar to those also used in the New Zealand National Mental Health Survey: Te Rau Hinengaro.[[18]] How well our health system is meeting the needs of an increasingly diverse population requires a representative sample across ethnic, social, and regional sub-populations. Inclusion of USEHN in the NZHS would also bring us into line with the many countries that routinely undertake relevant population surveys, countries that recognise that unmet need is an essential indicator of the effectiveness of healthcare systems.[[19–21]]
Health systems evolve, incrementally or as a result of structural reform. The New Zealand Health Reforms of the 1990s were based on neoliberal philosophy of a market for health with austerity budgeting. Hardy remnants of this failed philosophy remain embedded in the health system;[[22]] scant attention is still paid to the European and US studies that show investment in healthcare pays large fiscal dividends.[[1,2,7,23]] Prior to the Health Reforms of the 1990s, there were no procedural or structural obstructions to outpatient assessment and admission to hospital waiting lists which, therefore, gave at least a gross indication of the performance of the hospital systems and the level of USEHN. The Health Reforms of the 1990s included the introduction of clinical guidelines and movement from waiting lists to maximal waiting times. These and other barriers to access have left us with no barometers of the level of USEHN.
Central to the current Aotearoa health reforms is the aim of addressing inequalities, particularly for Māori, as well as ensuring improved access to health services, especially for those currently not well served by the system. To achieve these aims, the functions of the disestablished district health boards have been merged into Te Whatu Ora – Health New Zealand, a centralised model to provide “a simpler and more coordinated health system” (https://www.tewhatuora.govt.nz/) and a separate Te Aka Whai Ora – Māori Health Authority. Robust data, including those that cover both UPHN and USHN, will be essential to assess whether or not these aims of the current reforms are achieved.
Regular national surveys of USEHN are done in many countries.[[16]] The questions used have been validated in massive surveys and are still undergoing refinement.[[24,25]] Aotearoa New Zealand needs to adopt these tools to allow international benchmarking. The needed survey of USEHN must be done as part of the New Zealand Health Survey; they have the relevant expertise and would ensure a far more cost-effective approach than establishing a de novo study. As a result of our pilot study, we believe that there needs to be an initial broad survey of all aspects of USEHN, including Māori oversampling to assess regional and other fine details of disparities, followed by a focus on particular areas of USEHN as a core part of subsequent NZHSs.
Routine assessment of both PHN and SHN in the NZHS will be critical to monitor how well the health system is meeting health needs across the Aotearoa New Zealand population and to establish whether the current reforms and future evolution of the New Zealand health system achieve desired outcomes. Now, more than ever, with these health reforms underway with core goals of improving access and equity, it is time to act to properly measure unmet need. Without this, we will continue to live and work in a country that fails to understand and respond to the needs and suffering of our most poorly served.
Summary
Abstract
Aim
Method
Results
Conclusion
Author Information
Acknowledgements
Correspondence
Correspondence Email
Competing Interests
1) Bhattacharya J, Lakdawalla DN. The Labor Market Value of Health Improvements. Forum Health Econ Policy 2006;9(2).
2) Bloom DE, Canning D, Sevilla J. The Effect of Health on Economic Growth: A Production Function Approach. World Dev 2004;32(1):1-13.
3) Gostin LO, Boufford JI, Martinez RM. The Future Of The Public's Health: Vision, Values, And Strategies. Health Affairs 2004;23(4):96-107.
4) Mirvis DM, Chang CF, Cosby A. Health as an economic engine: evidence for the importance of health in economic development. J Health Hum Serv Adn 2008;31(1):30-57.
5) Murphy K, Topel R. Diminishing returns? The costs and benefits of improving health. Perspect Biol Med 2003;46(3 Suppl):S108-28.
6) New Zealand Medical Association. NZMA Position Statement: Health as an investment. https://assets-global. website-files.com/5e332a62c703f653182faf47/5e332a62c703f657212fc559_Health-as-an-investment_FINAL.pdf: New Zealand Medical Association, 2017.
7) Suhrcke M, McKee M, Stuckler D, et al. The contribution of health to the economy in the European Union. Public Health 2006;120(11):994-1001.
8) Reeves A, Basu S, McKee M, et al. Does investment in the health sector promote or inhibit economic growth? Global Health 2013;9(1):43.
9) Dahlgren G, Whitehead M. European strategies for tackling social inequities in health: Levelling up Part 2. https://www.euro.who.int/__data/assets/pdf_file/0018/103824/E89384.pdf: WHO Regional Office for Europe, 2006.
10) UN General Assembly. Sixty-seventh session. Agenda item 123: Global health and foreign policy. https://ncdalliance.org/sites/default/files/resource_files/Global%20Health%20and%20Foreign%20Policy%20resolution%202012_67th%20GA.pdf: United Nations, 2012.
11) GBD 2015 Healthcare Access and Quality Collaborators. Healthcare Access and Quality Index based on mortality from causes amenable to personal health care in 195 countries and territories, 1990–2015: a novel analysis from the Global Burden of Disease Study 2015. Lancet 2017;390(10091):231-66.
12) Cylus J, Papanicolas I. An analysis of perceived access to health care in Europe: How universal is universal coverage? Health Policy 2015;119(9):1133-44.
13) Rodney AM, Hill PS. Achieving equity within universal health coverage: a narrative review of progress and resources for measuring success. Int J Equity Health 2014;13(1):72.
14) Keene L, Bagshaw P, Nicholls MG, et al. Funding New Zealand's public healthcare system: time for an honest appraisal and public debate. N Z Med J 2016;129(1435):10-20.
15) Tobias M, Yeh LC. How much does health care contribute to health gain and to health inequality? Trends in amenable mortality in New Zealand 1981–2004. Aust NZ J Publ Heal 2009;33(1):70-8.
16) Bagshaw P, Bagshaw S, Frampton C, et al. Pilot study of methods for assessing unmet secondary health care need in New Zealand. N Z Med J 2017;130(1452):23-38.
17) Ministry of Health. Metholodology Report 2015/16: New Zealand Health Survey. Wellington: Ministry of Health, 2016.
18) Wells JE, Oakley Browne MA, Scott KM, et al. Te Rau Hinengaro: the New Zealand Mental Health Survey: overview of methods and findings. Aust NZ J Psychiat 2006;40(10):835-44.
19) Gauld R, Raymont A, Bagshaw PF, et al. The importance of measuring unmet healthcare needs. N Z Med J 2014;127(1404):63-7.
20) Reeves A, McKee M, Mackenbach J, et al. Public pensions and unmet medical need among older people: cross-national analysis of 16 European countries, 2004-2010. J Epidemiol Community Health 2017;71(2):174-80.
21) Fjaer EL, Stornes P, Borisova LV, et al. Subjective perceptions of unmet need for health care in Europe among social groups: Findings from the European social survey (2014) special module on the social determinants of health. Eur J Public Health 2017;27(suppl_1):82-9.
22) Barnett P, Bagshaw P. Neoliberalism: what it is, how it affects health and what to do about it. N Z Med J 2020;133(1512):76-84.
23) Masters R, Anwar E, Collins B, et al. Return on investment of public health interventions: a systematic review. J Epidemiol Community Health 2017;71(8):827-34.
24) Smith S, Connolly S. Re-thinking unmet need for health care: introducing a dynamic perspective. Health Econ Policy Law 2020;15(4):440-57.
25) Allan I, Ammi M. Evolution of the determinants of unmet health care needs in a universal health care system: Canada, 2001-2014. Health Econ Policy Law 2021;16(4):400-23.
Contact diana@nzma.org.nz
for the PDF of this article
Assessment of unmet secondary elective healthcare need—itself in need of acute care in Aotearoa New Zealand
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Unmet need in healthcare is a global issue, not least in Aotearoa New Zealand. Whether the health needs of a population are met—or not—is a critical indicator of the extent to which a health system provides comprehensive and equitable care. Although the health workforce may be aware of unmet healthcare needs on a local day-to-day basis, the issue for policy makers is deciding how best to allocate scarce national or regional resources. A central database that makes use of internationally standardised measures of unmet health need is vital for the development and implementation of health policy, despite the discomfort that arises when such a database inevitably exposes health system weaknesses and resource constraints. Without the use of standardised measures of unmet need, estimates are biased, international comparisons are flawed, and robust policy development and implementation is compromised. Improvements in health not only have enormous social value, they also lead to economic benefits for society.[[1–8]] Access to healthcare is a recognised determinant of health;[[9]] hence a strategy to make universal health coverage a worldwide objective (SDG Target 3.8) has been adopted by the United Nations.[[10]] Despite this, even in countries with state-funded health systems, there is evidence of unmet need and inequitable access to healthcare.[[11–13]]
In Aotearoa, although unmet primary healthcare need (UPHN) has been extensively and repeatedly estimated through the New Zealand Health Survey (NZHS), unmet secondary elective healthcare need (USEHN) has not. In this context, “elective” is to be distinguished from “acute or emergency” and characterises those to be admitted for care from a waiting list. Given that neither governments nor the New Zealand Ministry of Health have ever committed to the accurate assessment of USEHN, it is reasonable to wonder whether they really wish to know its true extent.
There have always been unacceptable ethnic and other socio-economic inequities in healthcare access and outcomes and these require urgent attention. USEHN, specifically, is a cause of unnecessary suffering, disability and death, and is also a modifiable cause of health inequalities.[[14,15]] In our 2017 pilot survey of USEHN, in which 29% of respondents reported UPHN, 9% reported USEHN that had been identified by a health professional.[[16]] Aotearoa has no accurate estimate of the prevalence of USEHN among Māori, so we lack basic understanding of the extent to which USEHN contributes to health inequalities between Māori and non-Māori.
Inclusion of appropriate questions on USEHN in the NZHS that can be benchmarked internationally would take advantage of the methods currently used in the national survey to obtain a representative sample[[17]]—methods similar to those also used in the New Zealand National Mental Health Survey: Te Rau Hinengaro.[[18]] How well our health system is meeting the needs of an increasingly diverse population requires a representative sample across ethnic, social, and regional sub-populations. Inclusion of USEHN in the NZHS would also bring us into line with the many countries that routinely undertake relevant population surveys, countries that recognise that unmet need is an essential indicator of the effectiveness of healthcare systems.[[19–21]]
Health systems evolve, incrementally or as a result of structural reform. The New Zealand Health Reforms of the 1990s were based on neoliberal philosophy of a market for health with austerity budgeting. Hardy remnants of this failed philosophy remain embedded in the health system;[[22]] scant attention is still paid to the European and US studies that show investment in healthcare pays large fiscal dividends.[[1,2,7,23]] Prior to the Health Reforms of the 1990s, there were no procedural or structural obstructions to outpatient assessment and admission to hospital waiting lists which, therefore, gave at least a gross indication of the performance of the hospital systems and the level of USEHN. The Health Reforms of the 1990s included the introduction of clinical guidelines and movement from waiting lists to maximal waiting times. These and other barriers to access have left us with no barometers of the level of USEHN.
Central to the current Aotearoa health reforms is the aim of addressing inequalities, particularly for Māori, as well as ensuring improved access to health services, especially for those currently not well served by the system. To achieve these aims, the functions of the disestablished district health boards have been merged into Te Whatu Ora – Health New Zealand, a centralised model to provide “a simpler and more coordinated health system” (https://www.tewhatuora.govt.nz/) and a separate Te Aka Whai Ora – Māori Health Authority. Robust data, including those that cover both UPHN and USHN, will be essential to assess whether or not these aims of the current reforms are achieved.
Regular national surveys of USEHN are done in many countries.[[16]] The questions used have been validated in massive surveys and are still undergoing refinement.[[24,25]] Aotearoa New Zealand needs to adopt these tools to allow international benchmarking. The needed survey of USEHN must be done as part of the New Zealand Health Survey; they have the relevant expertise and would ensure a far more cost-effective approach than establishing a de novo study. As a result of our pilot study, we believe that there needs to be an initial broad survey of all aspects of USEHN, including Māori oversampling to assess regional and other fine details of disparities, followed by a focus on particular areas of USEHN as a core part of subsequent NZHSs.
Routine assessment of both PHN and SHN in the NZHS will be critical to monitor how well the health system is meeting health needs across the Aotearoa New Zealand population and to establish whether the current reforms and future evolution of the New Zealand health system achieve desired outcomes. Now, more than ever, with these health reforms underway with core goals of improving access and equity, it is time to act to properly measure unmet need. Without this, we will continue to live and work in a country that fails to understand and respond to the needs and suffering of our most poorly served.
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Assessment of unmet secondary elective healthcare need—itself in need of acute care in Aotearoa New Zealand
A central database that makes use of internationally standardised measures of unmet health need is vital for the development and implementation of health policy, despite the discomfort that arises when such a database inevitably exposes health system weaknesses and resource constraints.
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