Equity in access to zero-fees and low-cost Primary Health Care in Aotearoa New Zealand: Results from repeated waves of the New Zealand Health Survey, 1996-2016

Equity, power and resources in primary health care reform: insights from Aotearoa New Zealand

BACKGROUND

New Zealand's District Health Board reform (2000-2022) was underpinned by the goal of reducing inequities in health outcomes between population groups and improving health overall. A key policy vehicle for achieving the goal was a system-wide shift to population health with increased strategic focus on and investment in primary health care.

METHODS

This research explored shifts in power and resource to understand how equity as a policy goal for primary health care fared over the District Health Board era, and examined how the distribution of power and resources in the health sector changed for PHC over the period 2000-2020. The study used an exploratory case study methodology based on insights from key informant interviews.

RESULTS

The study found that despite policy intent, actors holding political power shaped health outcomes under the reforms, curtailing the mechanisms that could have made a significant impact on equitable health outcomes between population groups.

CONCLUSION

It concludes that exploring power and resource shifts sheds light on power dynamics within a reform. Since power shapes how resources are deployed, attention to power and resource complements technical elements of health system reform, by helping to understand where and how to intervene so that reforms achieve their desired goals.

Patterns of Health Services and Medicine Utilisation by First-Generation Pakistani Immigrants in New Zealand

INTRODUCTION

The health-seeking patterns of the increasing Pakistani migrant population in New Zealand (NZ) is a subject of limited research in current literature. Therefore, the study aimed to investigate and understand the patterns of health services utilisation and medicine usage among first-generation Pakistani immigrants in NZ.

METHODS

Convenience and snowball sampling using social media platforms were used to conduct eleven semi-structured interviews consisting of two participants per interview. The interviews were audio-taped and transcribed verbatim. Data were analysed iteratively using an inductive thematic approach.

RESULTS

Self-medication emerged as a common practice by the majority of the participants and this practice stemmed from personal experiences, existing knowledge, and personal and cultural beliefs. However, participants had limited knowledge of the NZ health system and community pharmacy services and this led to conflicting expectations and outcomes. These factors serve as barriers to healthcare access for Pakistani immigrants and can result in adverse health outcomes and higher rates of dissatisfaction.

CONCLUSION

This study highlights the healthcare challenges and behaviours of Pakistani immigrants in NZ, emphasising their reliance on traditional remedies and self-medication. While appreciating the quality of NZ's healthcare, participants faced barriers like cost and lack of awareness of pharmacy services. The findings call for culturally tailored strategies to improve accessibility and healthcare experiences for immigrants.

PATIENT OR PUBLIC CONTRIBUTION

Two individuals from the Pakistani community, not part of the study, contributed to the design by offering feedback and pilot testing the interview guide. Based on their input, adjustments were made to enhance the clarity of the questions from a patient's or public viewpoint. No new questions were proposed as a result of this feedback.

Financial barriers to primary health care in Aotearoa New Zealand

BACKGROUND

In Aotearoa New Zealand, co-payments to see a general practitioner (GP, family doctor) or collect a prescription are payable by virtually all adults.

OBJECTIVE

To examine the extent to which these user co-payments are a barrier to accessing health care, focussing on inequities for indigenous Māori.

METHODS

Pooled data from sequential waves (years) of the New Zealand Health Survey, 2011/12 to 2018/19 were analysed. Outcomes were self-reported cost barriers to seeing a GP or collecting a prescription in the previous year. Logistic regression was used to estimate odds ratios (ORs) of barriers to care for Māori compared with non-Māori, sequentially adjusting for additional explanatory variables.

RESULTS

Pooled data included 107,231 people, 22,292 (21%) were Māori. Across all years, 22% of Māori (13% non-Māori) experienced a cost barrier to seeing a GP, and 14% of Māori (5% non-Māori) reported a cost barrier to collecting a prescription. The age- and wave-adjusted OR comparing Māori/non-Māori was 1.71 (95% confidence interval [CI]: 1.61, 1.81) for the cost barrier to primary care and 2.97 (95% CI: 2.75, 3.20) for the cost barrier to collecting prescriptions. Sociodemographics accounted for about half the inequity for both outcomes; in a fully adjusted model, age, sex, low income, and poorer underlying health were determinants of both outcomes, and deprivation was additionally associated with the cost barrier to collecting a prescription but not to seeing a GP.

CONCLUSIONS

Māori experience considerable inequity in access to primary health care; evidence supports an urgent need for change to system funding to eliminate financial barriers to care.

Practice pharmacists in the primary healthcare team in Aotearoa New Zealand: a national survey

Introduction The integration of pharmacists into general practice settings is increasingly common internationally. Within Aotearoa New Zealand, the role has evolved variably in different regions. Recent health policy and professional guidance support further development. Aim To describe the current status of pharmacists working in primary healthcare settings other than community pharmacy. Methods An online survey of all pharmacists in Aotearoa New Zealand primary healthcare settings was conducted in 2022, and covered employment, current services, patient consultations, relationships with other health professionals, and service costs and benefits. Descriptive statistical analyses were performed. Results Responses from 39 pharmacists (~35% response rate) working in primary healthcare practice roles are reported. Most were female (84%), New Zealand European (81%), and 45% had Discussion Practice pharmacists have both patient- and practice-facing roles. The proportion with a prescribing qualification has increased over time. There is some capacity for additional consultations, but this requires funding, space and time spent in a service/setting.

What Interventions Work to Reduce Cost Barriers to Primary Healthcare in High-Income Countries? A Systematic Review

High-income countries like Aotearoa New Zealand are grappling with inequitable access to healthcare services. Out-of-pocket payments can lead to the reduced use of appropriate healthcare services, poorer health outcomes, and catastrophic health expenses. To advance our knowledge, this systematic review asks, "What interventions aim to reduce cost barriers for health users when accessing primary healthcare in high-income countries?" The search strategy comprised three bibliographic databases (Dimensions, Embase, and Medline Web of Science). Two authors selected studies for inclusion; discrepancies were resolved by a third reviewer. All articles published in English from 2000 to May 2022 and that reported on outcomes of interventions that aimed to reduce cost barriers for health users to access primary healthcare in high-income countries were eligible for inclusion. Two blinded authors independently assessed article quality using the Critical Appraisal Skills Program. Relevant data were extracted and analyzed in a narrative synthesis. Forty-three publications involving 18,861,890 participants and 6831 practices (or physicians) met the inclusion criteria. Interventions reported in the literature included removing out-of-pocket costs, implementing nonprofit organizations and community programs, additional workforce, and alternative payment methods. Interventions that involved eliminating or reducing out-of-pocket costs substantially increased healthcare utilization. Where reported, initiatives generally found financial savings at the system level. Health system initiatives generally, but not consistently, were associated with improved access to healthcare services.

The enrolment gap: who is not enrolling with primary health organizations in Aotearoa New Zealand and what are the implications? An exploration of 2015-2019 administrative data

BACKGROUND

Primary Health Care (PHC) is the entry point to accessing health services in many countries. Having a high proportion of the population enrolled with a PHC provider is key to ensuring PHC fulfils this role and that it contributes to achieving better equity in health. We aimed to understand the extent to which people in Aotearoa New Zealand are enrolling with Primary Health Organizations (PHOs), how enrolment rates have evolved over time, and variations across District Health Boards (DHBs) and socio-demographic groups.

METHODS

We analysed administrative data on the proportion of people enrolled in PHOs and breakdowns across DHBs, and by age, ethnicity and deprivation, for the years 2015-2019.

RESULTS

About 6% of the population was not enrolled in 2019. There are persistent differences across socio-demographic groups as well as geographically. Māori have lower enrolment rates than New Zealand European/Other groups. Young people (15-24 years) are the least likely to be enrolled. The most affluent areas have the highest enrolment rates. Auckland DHB shows the lowest enrolment rates.

CONCLUSIONS

Enrolments remain below full population coverage and inequities exist between socio-demographic and geographic groups. Potential reasons explaining these trends include methodological limitations as well as real issues in accessing services. We recommend (a) work towards minimising data issues in relation to this indicator to improve its accuracy and value in signalling trends in access to PHC services, and (b) investigating the reasons for the potential widening of the inequities identified, in particular issues preventing Māori and younger people from enrolling. This study deepens our understanding of enrolment rates as an indicator for tracking equity in PHC. Other countries can learn from the Aotearoa New Zealand case to draw lessons for improving equity in health care.