New Zealand Pae Ora Healthcare Reforms 2022: Viable by Design? A qualitative Study using the Viable System Model

Document Type : Original Article

Authors

1 Department of General Practice and Rural Health, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand

2 Department of Business Studies, University of Iceland, Saemundargata, Reykjavik, Iceland

3 DBA Programme, Otago Business School, University of Otago, Dunedin, New Zealand

4 Department of Management, Otago Business School, University of Otago, Dunedin, New Zealand

Abstract

Background 
The New Zealand (NZ) Pae Ora (Healthy Futures) health reforms came into effect in July 2022 with the establishment of Health New Zealand (Te Whatu Ora) and the Māori Health Authority (Te Aka Whai Ora) – the organisations charged for healthcare provision and delivery. Given these changes represent major health system reform, we aimed to conduct an early evaluation of the design of the reforms to determine if they can deliver a viable and sustainable NZ health system going forward.

Methods 
The evaluation was informed by Beer’s Viable System Model (VSM). A qualitative exploratory design with semi-structured interviews and documents analysis using thematic analysis was used. We conducted 28 interviews with senior healthcare managers and reviewed over 300 official documents and news analyses.

Results 
The VSM posits that for a system to be viable, all its five sub-systems (operations; co-ordination; operational control; development and governance) need to be strong. Our analysis suggests that the health reforms, despite their strengths, do not satisfy this requirement. The reforms do appreciate the complexity of the healthcare environment: multiple stakeholders, social inequalities, interdependencies. However, our analysis suggests a severe lack of detail regarding the implementation and operationalisation of the reforms. Furthermore, resourcing and coordination within the reformed system is also unclear.

Conclusions 
The health system reforms may not lead to a viable future NZ health system. Poor communication of the reform implementation and operationalisation will likely result in system failure and inhibit the ability of frontline health organisations to deliver care.

Keywords

References

  1. Health and Disability System Review. Health and Disability System Review – Final Report – Pūrongo Whakamutunga. Wellington: HDSR2020.
  2. DPMC. Future of Health. 2021.
  3. Hobbs M, Ahuriri-Driscoll A, Marek L, Campbell M, Tomintz M, Kingham S. Reducing health inequity for Maori people in New Zealand. The Lancet. 2019;394(10209):1613-1614. doi:10.1016/S0140-6736(19)30044-3
  4. New Zealand Parliament. Pae Ora (Healthy Futures) Act 20222022.
  5. DPMC. How our health system is changing / E panoni ana tō tātou hātepe hauora. 2021; https://www.futureofhealth.govt.nz/about-the-reforms/how-health-system-changing/.
  6. Dwyer J. Australian health system restructuring–what problem is being solved? Australia and New Zealand health policy. 2004;1(6). doi:10.1186/1743-8462-1-6
  7. Wishnia J, Goudge J. Impact of financial management centralisation in a health system under austerity: a qualitative study from South Africa. BMJ Global Health. 2020;5(10):e003524. doi:10.1136/bmjgh-2020-003524
  8. Sparrow R, Budiyati S, Yumna A, Warda N, Suryahadi A, Bedi AS. Sub-national health care financing reforms in Indonesia. Health Policy Plan. 2017;32(1):91-101. doi:10.1093/heapol/czw101
  9. Kidd MR. What impact will the Australian Government’s proposed national health care reforms have on Australian general practice. Med J Aust. 2009;191(2):55-57.
  10. Pansiri J, Mmereki RN. Using the Servqual Model to Evaluate the Impact of Public Service Reforms in the Provision of Primary Health Care in Botswana. Journal of African Business. 2010;11(2):219-234. doi:10.1080/15228916.2010.509005
  11. Greenfield D, Hinchcliff R, Banks M, et al. Analysing ‘big picture’ policy reform mechanisms: the Australian health service safety and quality accreditation scheme. Health Expect. 2015;18(6):3110-3122. doi:https://doi.org/10.1111/hex.12300
  12. Setswe G, Witthuhn J, Muyanga S, Nyasulu P. The new National Health Insurance policy in South Africa: Public perceptions and expectations. International Journal of Healthcare Management. 2016;9(2):77-82. doi:10.1080/20479700.2016.1142695
  13. Atun R, de Andrade LOM, Almeida G, et al. Health-system reform and universal health coverage in Latin America. The Lancet. 2015;385(9974):1230-1247. doi:https://doi.org/10.1016/S0140-6736(14)61646-9
  14. Berman P, Bossert T. A decade of health sector reform in developing countries: what have we learned. Washington, UNAID. 2000.
  15. Oliver TR. The politics of public health policy. Annu Rev Public Health. 2006;27:195-233.
  16. Cunningham FC, Ranmuthugala G, Westbrook JI, Braithwaite J. Tackling the wicked problem of health networks: the design of an evaluation framework. BMJ Open. 2019;9(5):e024231. doi:10.1136/bmjopen-2018-024231
  17. Petticrew M, Tugwell P, Welch V, et al. Better evidence about wicked issues in tackling health inequities. Journal of Public Health. 2009;31(3):453-456. doi:10.1093/pubmed/fdp076
  18. Plamondon KM, Pemberton J. Blending integrated knowledge translation with global health governance: an approach for advancing action on a wicked problem. Health Res Policy Syst. 2019;17(1):24. doi:10.1186/s12961-019-0424-3
  19. Rittel HW, Webber MM. Dilemmas in a general theory of planning. Policy sciences. 1973;4(2):155-169.
  20. Braithwaite J, Churruca K, Long JC, Ellis LA, Herkes J. When complexity science meets implementation science: a theoretical and empirical analysis of systems change. BMC Med. 2018;16(1):63. doi:10.1186/s12916-018-1057-z
  21. Dominis S, Yazbeck AS, Hartel LA. Keys to Health System Strengthening Success: Lessons from 25 Years of Health System Reforms and External Technical Support in Central Asia. Health Systems & Reform. 2018;4(2):160-169. doi:10.1080/23288604.2018.1440348
  22. Hoverstadt P. The fractal organization: Creating sustainable organizations with the viable system model. London: John Wiley & Sons; 2011.
  23. Hildbrand S, Bodhanya S. Guidance on applying the viable system model. Kybernetes. 2015.
  24. Devine S. The Viable Systems Model Applied to a National System of Innovation to Inform Policy Development. Systemic Practice and Action Research. 2005;18(5):491-517. doi:10.1007/s10979-005-8485-y
  25. Beer S. Diagnosing the system for organisations. Chichester: Wiley; 1985.
  26. Beer S. The viable system model: Its provenance, development, methodology and pathology. J Oper Res Soc. 1984;35(1):7-25.
  27. Harwood SA. A question of interpretation: The Viable System Model (VSM). European Journal of Operational Research. 2019;274(3):1198-1201. doi:https://doi.org/10.1016/j.ejor.2018.10.054
  28. Akmal A, Podgorodnichenko N, Foote J, Greatbanks R, Stokes T, Gauld R. Why is Quality Improvement so Challenging? A Viable Systems Model Perspective to Understand the Frustrations of Healthcare Quality Improvement Managers. Health Policy. 2021;125(5):658-664. doi:https://doi.org/10.1016/j.healthpol.2021.03.015
  29. Raisio H. Health care reform planners and wicked problems: is the wickedness of the problems taken seriously or is it even noticed at all? Journal of Health Organization and Management. 2009;23(5):477-493.
  30. Mosadeghrad AM. Factors Affecting Medical Service Quality. Iran Journal of Public Health. 2014;43(2):210-220.
  31. Tin Tin S, Elwood JM, Brown C, et al. Ethnic disparities in breast cancer survival in New Zealand: which factors contribute? BMC Cancer. 2018;18(1):58. doi:10.1186/s12885-017-3797-0
  32. Marmot M, Allen JJ. Social Determinants of Health Equity. Am J Public Health. 2014;104(S4):S517-S519. doi:10.2105/AJPH.2014.302200
  33. Veenstra G. Social status and health: absolute deprivation or relative comparison, or both? Health Sociology Review. 2005;14(2):121-134.
  34. Napier AD, Ancarno C, Butler B, et al. Culture and health. The Lancet. 2014;384(9954):1607-1639. doi:10.1016/S0140-6736(14)61603-2
  35. Bourke S, Wright A, Guthrie J, Russell L, Dunbar T, Lovett R. Evidence Review of Indigenous Culture for Health and Wellbeing. International Journal of Health, Wellness & Society. 2018;8(4):11-27. doi:10.18848/2156-8960/CGP/v08i04/11-27
  36. Lidler E. Definitions of health and illness and medical sociology. Social Science & Medicine. Part A: Medical Psychology & Medical Sociology. 1979;13:723-731. doi:https://doi.org/10.1016/0271-7123(79)90118-4
  37. Hyder A, Syed S, Puvanachandra P, et al. Stakeholder analysis for health research: Case studies from low- and middle-income countries. Public Health. 2010;124(3):159-166. doi:https://doi.org/10.1016/j.puhe.2009.12.006
  38. Smith MA, Hall M, Lew J-B, Canfell K. Potential for HPV vaccination and primary HPV screening to reduce cervical cancer disparities: Example from New Zealand. Vaccine. 2018;36(42):6314-6324. doi:https://doi.org/10.1016/j.vaccine.2018.08.063
  39. Cyr ME, Etchin AG, Guthrie BJ, Benneyan JC. Access to specialty healthcare in urban versus rural US populations: a systematic literature review. BMC Health Serv Res. 2019;19(1):974. doi:10.1186/s12913-019-4815-5
  40. Eggleton K, Bui N, Goodyear-Smith F. COVID-19 impact on New Zealand general practice: rural–urban differences. Rural and Remote Health. 2022;22(1). doi:https://doi.org/10.22605/RRH7185
  41. Petrie S, Peters P. Untangling complexity as a health determinant: Wicked problems in healthcare. Health Science Inquiry. 2020;11(1):131-135.
  42. Gates B. How to prevent the next pandemic: Knopf Canada; 2022.
  43. Hill PS. Understanding global health governance as a complex adaptive system. Global Public Health. 2011;6(6):593-605. doi:10.1080/17441691003762108
  44. Braithwaite J. Changing how we think about healthcare improvement. BMJ. 2018;361:k2014. doi:10.1136/bmj.k2014
  45. Olszewska-Guizzo A, Fogel A, Benjumea D, Tahsin N. Sustainable Solutions in Urban Health: Transdisciplinary Directions in Urban Planning for Global Public Health. In: Leal Filho W, Vidal DG, Dinis MAP, Dias RC, eds. Sustainable Policies and Practices in Energy, Environment and Health Research: Addressing Cross-cutting Issues. Cham: Springer International Publishing; 2022:223-243.
  46. Andrawes L, Johnson T, Coleman M. Complexity in Health: Can Design Help Support Interdisciplinary Solutions? Global Health: Science and Practice. 2021;9(Supplement 2):S217. doi:10.9745/GHSP-D-21-00222
  47. Babar Z-U-D, Francis S. Identifying priority medicines policy issues for New Zealand: a general inductive study. BMJ Open. 2014;4(5):e004415. doi:10.1136/bmjopen-2013-004415
  48. Ministry of Health. District Health Boards. 2018; https://www.health.govt.nz/new-zealand-health-system/key-health-sector-organisations-and-people/district-health-boards. Accessed 13 May, 2018.
  49. Ministry of Health. Better, Sooner, More Convenient Health Care in the Community. Wellington: Ministry of Health;2011.
  50. Tenbensel T, Cumming J, Willing E. The 2022 restructure of Aotearoa New Zealand's health system: Will it succeed in advancing equity where others have failed? Health Policy. 2023:104828.
  51. Yanow D. Thinking interpretively: Philosophical presuppositions and the human sciences. In: Yanow D, Schwartz-Shea IP, eds. Interpretation and method: Empirical research methods and the interpretive turn. 2nd ed. New York, NY: Routledge; 2014:5-26.
  52. Crabtree BF, Miller WL. Doing qualitative research. London: Sage Publications; 1999.
  53. HRC. Do locality network partnerships improve health system performance and outcomes? 2020; https://www.hrc.govt.nz/resources/research-repository/do-locality-network-partnerships-improve-health-system-performance.
  54. Akmal A, Gauld R. What components are important for effective healthcare alliance governance? Findings from a modified Delphi study in New Zealand. Health Policy. 2021;125(2):239-245. doi:https://doi.org/10.1016/j.healthpol.2020.12.012
  55. Creswell JW. Qualitative inquiry and research design: Choosing among five approaches. Thousand Oaks, CA: Sage Publications, Inc.; 2013.
  56. Coffey A. Analysing documents. The SAGE handbook of qualitative data analysis. 2014:367-380.
  57. Braun V, Clarke V. Using thematic analysis in psychology. Qualitative Research in Psychology. 2006;3(2):77-101. doi:10.1191/1478088706qp063oa
  58. Bazeley P, Jackson K. Qualitative data analysis with NVivo. London: Sage Publications Ltd.; 2013.
  59. Lincoln YS, Guba EG. Naturalistic inquiry. Thousand Oaks, CA: Sage Publications, Inc.; 1985.
  60. Amis JM, Silk ML. The philosophy and politics of quality in qualitative organizational research. Organizational Research Methods. 2008;11(3):456-480. doi:10.1177/1094428107300341
  61. Akmal A, Podgorodnichenko N, Greatbanks R, Zhang JA. Does organizational readiness matter in lean thinking practices? An agency perspective. International Journal of Operations & Production Management. 2022;ahead-of-print(ahead-of-print). doi:10.1108/IJOPM-05-2021-0331
  62. Tjora A. Qualitative Research as Stepwise-Deductive Induction: A Stepwise-Deductive Inductive Approach: Routledge; 2018. 63. Whittemore R, Chase SK, Mandle CL. Validity in qualitative research. Qual Health Res. 2001;11(4):522-537. doi:10.1177/104973201129119299
  63. Morse JM. Critical analysis of strategies for determining rigor in qualitative inquiry. Qual Health Res. 2015;25(9):1212-1222. doi:10.1177/1049732315588501
  64. Koelsch LE. Reconceptualizing the member check interview. International Journal of Qualitative Methods. 2013;12(1):168-179. doi:10.1177/160940691301200105
  65. Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. Int J Qual Health Care. 2007;19(6):349-357. doi:10.1093/intqhc/mzm042
  66. Andrews A. Investigating technical efficiency and its determinants: The Case of New Zealand District Health Boards. Health Policy and Technology. 2020;9(3):323-334. doi:https://doi.org/10.1016/j.hlpt.2020.04.006
  67. Chittock N. Burned out or leaving for overseas: Midwifery sector in downward spiral, says union. RNZ. 7 June 2022, 2022.
  68. Corlett E. 'Crap pay and horrible conditions': Midwives at breaking point in capital DHB. RNZ. 17 February 2021, 2021.
  69. Quinn R. Midwife shortage at Invercargill Hospital an 'extreme risk' - DHB. RNZ. 7 December 2021, 2021.
  70. Checkpoint. Seeing your doctor harder as GP shortage worsens. RNZ. 16 March 2022, 2022.
  71. Donovan E. The urgent need for more GPs. RNZ. 7 APril 2022, 2022.
  72. Report M. Nurses organisation concerned shortage will get worse. RNZ. 7 June 2022, 2022.
  73. RNZ. Thousands of nursing vacancies set to test hospitals over winter - union. RNZ. 15 May 2022, 2022.
  74. Hall M. Napier urgent-care clinic closed due to staff shortage. NZ Doctor. 31 May 2022, 2022.
  75. Leask J. Services being reviewed in effort to ease pressure on Ashburton Hospital. RNZ. 8 February 2022, 2022.
  76. Noon Nt. Overflowing emergency departments "a perfect storm". RNZ. 3 June 2022, 2022.
  77. Rosenberg M. Unit closure another blow for Wairoa healthcare. RNZ. 4 April 2022, 2022.
  78. Houlahan M. Stresses mount on hospital nursing staff. Otago Daily TImes. 4 June 2022, 2022.
  79. Quinn R. Hospitals consistently understaffed, nurses overworked - report. RNZ. 17 February 2022, 2022.
  80. Argyris C. Double-Loop Learning, Teaching, and Research. Academy of Management Learning & Education. 2002;1(2):206-218. doi:10.5465/amle.2002.8509400
  81. de Vries MS, de Vries MS. Repetitive reorganizations, uncertainty and change fatigue. Public Money & Management. 2021:1-10.
  82. Akmal A, Foote J, Podgorodnichenko N, Greatbanks R, Gauld R. Understanding resistance in lean implementation in healthcare environments: an institutional logics perspective. Production Planning & Control. 2022;33(4):356-370. doi:10.1080/09537287.2020.1823510
  83. He AJ, Ma L. Citizen participation, perceived public service performance, and trust in government: Evidence from health policy reforms in Hong Kong. Public Performance & Management Review. 2021;44(3):471-493.
  84. Health and Disability System Review. Health and Disability System Review - Interim Report. Hauora Manaaki ki Aotearoa Whānui – Pūrongo mō Tēnei Wā. Wellington2019.
  85. MacNamara K. Health system reform: 'Transition Unit' to spend $18m on consultants this year. NZ Herald2021.
  86. Johnston M. FIX: A who’s who of health reformers. NZ Doctor2021.
  87. Anand G, Gray JV. Strategy and organization research in operations management. Journal of Operations Management. 2017;53-56:1-8. doi:https://doi.org/10.1016/j.jom.2017.09.001
  88. Schwaninger M, Scheef C. A test of the viable system model: theoretical claim vs. empirical evidence. Cybernetics and systems. 2016;47(7):544-569.
  89. Dixon-Woods M. How to improve healthcare improvement—an essay by Mary Dixon-Woods. BMJ. 2019;367:l5514. doi:10.1136/bmj.l5514
  90. Dixon-Woods M, McNicol S, Martin G. Ten challenges in improving quality in healthcare: lessons from the Health Foundation’s programme evaluations and relevant literature. BMJ Quality & Safety. 2012;21(10):876. doi:10.1136/bmjqs-2011-000760
  91. Schuitmaker TJ. Identifying and unravelling persistent problems. Technological Forecasting and Social Change. 2012;79(6):1021-1031. doi:https://doi.org/10.1016/j.techfore.2011.11.008
  92. Pepler EF, Pridie J, Brown S. Predicting and testing a silo-free delivery system. Healthc Manage Forum. 2018;31(5):200-205. doi:10.1177/0840470418793910
  93. Rifkin SB, Fort M, Patcharanarumol W, Tangcharoensathien V. Primary healthcare in the time of COVID-19: breaking the silos of healthcare provision. BMJ Global Health. 2021;6(11):e007721. doi:10.1136/bmjgh-2021-007721
  94. Dalton S. The ugly state of Kiwi oral health. NZ Doctor2022.
  95. Docherty B. Let’s see nursing crisis as a blip. NZ Doctor2022.
  96. Johnston M. Doctor shortage reduces after-hours service at Hokianga Hospital. NZ Doctor2022.
  97. Severn M. Tackling the audiologist shortage. NZ Doctor2022.
  98. Todd K. GP crisis: About half NZ's clinics not taking new patients2022.
  99. Braithwaite J, Ludlow K, Testa L, et al. Built to last? The sustainability of healthcare system improvements, programmes and interventions: a systematic integrative review. BMJ Open. 2020;10(6):e036453. doi:10.1136/bmjopen-2019-036453
  100. Smith PC. Performance Measurement in Health Care: History, Challenges and Prospects. Public Money & Management. 2005;25(4):213-220. doi:10.1080/09540962.2005.10600096
  101. Sheldon TA. The healthcare quality measurement industry: time to slow the juggernaut? Quality and Safety in Health Care. 2005;14(1):3. doi:10.1136/qshc.2004.013185
  102. Mannion R, Braithwaite J. Unintended consequences of performance measurement in healthcare: 20 salutary lessons from the English National Health Service. Intern Med J. 2012;42(5):569-574. doi:10.1111/j.1445-5994.2012.02766.x
  103. Smith PC, Mossialos E, Papanicolas I, Leatherman S. Performance measurement for health system improvement: experiences, challenges and prospects. Cambridge UK: Cambridge University Press; 2009.
  104. Greener I. Healthcare funding and its relationship to equity and outcomes: A QCA analysis of Commonwealth Fund and OECD data. Journal of European Social Policy. 2020;30(4):480-494. doi:10.1177/0958928720905290
  105. Taylor LA, Tan AX, Coyle CE, et al. Leveraging the Social Determinants of Health: What Works? PLoS One. 2016;11(8):e0160217. doi:10.1371/journal.pone.0160217
  106. Williams DR, Costa MV, Odunlami AO, Mohammed SA. Moving Upstream: How Interventions That Address the Social Determinants of Health Can Improve Health and Reduce Disparities. J Public Health Manag Pract. 2008;14(6).
  107. Adler NE, Glymour MM, Fielding J. Addressing Social Determinants of Health and Health Inequalities. JAMA. 2016;316(16):1641-1642. doi:10.1001/jama.2016.14058
  108. Harrison R, Fischer S, Walpola RL, et al. Where do models for change management, improvement and implementation meet? A systematic review of the applications of change management models in healthcare. Journal of healthcare leadership. 2021:85-108.
  109. Knight DR, Palmer MS. The Constitution of New Zealand. London: Hard Publishing; 2022.
  110. Ranta A, Ingham B, Harwood M. Stroke among Māori in Aotearoa New Zealand and solutions to address persistent inequities. Frontiers in Stroke.2:1248351.
  111. Espejo R, Harnden R. The viable system model. Systems practice. 1990;3(3):219-221.
  112. Staw BM, Sandelands LE, Dutton JE. Threat rigidity effects in organizational behavior: A multilevel analysis. Adm Sci Q. 1981:501-524.
International Journal of Health Policy and Management

Articles in Press, Accepted Manuscript
Available Online from 21 November 2023

Files

History

  • Receive Date: 22 December 2022
  • Revise Date: 25 October 2023
  • Accept Date: 20 November 2023
  • First Publish Date: 21 November 2023

Share

How to cite

Statistics