Implementing the primary health care strategy: a Maori health provider perspective.

• Author: Abel, Sally
• Position: Research Papers

Abstract

This paper discusses the development of Ngati Porou Hauora (NPH), an East Coast Maori health provider, into a Primary Health Organisation (PHO), the cornerstone of the Primary Health Care Strategy (PHCS). It illustrates how NPH's structure, philosophy of care and service delivery were compatible with the frameworks underpinning both the PHCS and He Korowai Oranga: The Maori Health Strategy, thus facilitating PHO development. The paper also examines some of the challenges of implementing the PHCS, such as integrating a population health approach, the appropriateness of key performance indicators and issues to do with community participation and partnership, funding and contracting. It concludes that, while larger Maori health providers like NPH and those that have formed equitable partnerships with other third sector providers have been strengthened by the strategies and have some valuable lessons for the primary health sector, there remain inherent risks for smaller Maori health providers.

INTRODUCTION

With the introduction of the Primary Health Care Strategy (PHCS) in 2001, the New Zealand Government aimed to establish a primary health care structure providing comprehensive coordinated services to enrolled populations and reducing inequalities in health status (King 2001). This was to be achieved through the development of Primary Health Organisations (PHOs), which would receive capitated funding and be required to:

* undertake population health initiatives alongside patient-centred primary care

* broaden the range of providers and skills used in integrated primary care delivery

* improve access to services for disadvantaged populations

* ensure community participation in health care service decision-making and governance.

Implicit in this was a community development approach and an emphasis on intersectoral work at both individual and population levels.

This holistic approach was quite new to the New Zealand primary health care scene that had traditionally been focused on general practitioner clinical services and funded on a fee-for-service basis. But for many Maori and other third sector primary health providers, (2) whose structures, philosophies and approaches to primary care provision already sat very comfortably with this new direction, the changes were welcomed for the most part. Although the new structures have been problematic for some of the smaller Maori heath providers, others have developed relatively quickly into or within PHOs because their governance structures and strategic aims around access to care were compatible with the Strategy and the demographic features of their populations qualified them for full population funding. Their approaches to health care delivery have been further validated by the release of He Korowai Orange: The Maori Health Strategy (HKO) (King and Turia 2002a) in 2002, and its action plan Whakatataka (King and Turia 2002b).

Using Ngati Porou Hauora (NPH) as a case study, this paper examines the implementation of the PHCS within a well-established and relatively large Maori health provider. Following a brief background on the development of PHOs, Maori health providers and NPH, we examine how NPH's structure, philosophy of care and service delivery were compatible with the frameworks underpinning PHCS and HKO and how this facilitated the transition into a PHO. We then go on to describe a number of challenges that have been encountered in the PHO development process that may have relevance for other providers. Finally, we conclude that, although the strategies have strengthened larger Maori health providers like NPH and those that have formed equitable partnerships with other third sector providers, there remain inherent risks for smaller Maori health providers.

PRIMARY HEALTH ORGANISATION DEVELOPMENT

Since the introduction of the PHCS in 2001 and the establishment of the first PHOs in July 2002, significant changes have occurred within the primary health care sector. The formation of PHOs has occurred much more rapidly than Government originally intended. Although the original timeframe to enrol the entire New Zealand population was 8-10 years, by October 2004, 91% of the population was enrolled by 77 PHOs. Over three-quarters of Maori, almost all Pacific peoples and almost 80% of those in the most deprived areas (NZDep deciles 9 and 10) were enrolled and services were available at reduced or low cost to approximately half the general population (King 2004:97, Spencer 2004). While there has been general support from providers for the overall direction of the reforms, some of the implementation processes have been challenged, not least the inconsistencies in contracting and monitoring between the 21 District Health Boards (DHBs) with whom PHOs obtain contracts (Austin 2003, Perera et al. 2003). Indeed while some DHBs are happy to contract with small (3) PHOs, others are not (New Zealand Doctor 2005a).

Funding formulae, governance issues and internal PHO relationships have also been stumbling blocks. With respect to the funding formulae, the intention of Government was to target resources at high-need populations first. PHOs with registers that met the high-need criteria (registered populations where 50% or more were Maori, Pacific and/or of NZDep deciles 9 and 10) qualified for the more generous Access funding formula. Others were granted the Interim funding formula, a lower per capita amount targeted at the young and the old with a view to augmentation as further funding came on stream (Ministry of Health 2002).

However, the differential in the formulae has attracted considerable criticism. In particular, those PHOs whose populations were considered less high need as a group, but who nevertheless had many individuals with high need, have complained that Access providers have been able to offer lower-cost services to their enrolled populations more quickly and, arguably, attract patients from providers that did not have this advantage (Barnett and Barnett 2004, Spencer 2004). Consequently, by the end of 2004 Government had announced that they intended to expedite the PHCS implementation process, with all PHOs on Access formula funding by the end of 2007 (New Zealand Doctor 2005b).

Governance requirements have also been an issue. Many general practitioners are in private practice and there has been some reluctance to include community members in governance because of a potential influence on their professional and business practices. In an effort to reduce general practitioner resistance to the new structures, the community participation imperative became increasingly watered down in successive versions of the PHCS policy (Neuwelt and Crampton 2004). Indeed part of the rapid development of non-third-sector PHOs has been enabled by the tolerance that many DHBs have shown in relation to governance and community participation practices that did not strictly meet the requirements of the initial strategy. At the fifth joint Ministry of Health/Non-Government Organisations (NGO) Health and Disability Forum held in March 2004, the tension between the business and community service models was identified as a pressing issue for DHBs, and one of the key concerns raised by NGOs was their lack of meaningful participation at governance level because of "perceived GP and mainstream provider capture of PHOs" (Ministry of Health 2004a).

Provider relationships within PHOs have also posed difficulties. A few PHOs have collapsed altogether and in others some partner providers have left because the member provider-groups have not been able to work together (New Zealand Doctor 2005b).

MAORI HEALTH PROVIDERS

The number of Maori health providers has burgeoned over the past decade. Following the restructuring of the health system in the early 1990s new opportunities opened for Maori health provider contracts under the newly established Regional Health Authorities (Crengle 1999). This continued through successive restructuring, so that by 2004 there were 240 such providers throughout the country (King 2004). While many of these providers hold small specific contracts, others are much larger and offer a wide range of services, including medical, nursing, allied health professional services and community care. The commonality, irrespective of size, has been the "ownership" of the provider by a tribal or community-based group, the lack of medical dominance in governance and the use of tikanga Maori or Maori-defined frameworks for understanding health and delivering health care (Crengle 1999). Also, Maori providers have generally focused on providing easier access to services for their clients and have been driven by the evident disparities in health between the Maori and non-Maori communities (see Reid et al. 2000, Ajwani et al. 2003). Both of the latter are now features of the PHCS, and remain so despite political challenges about focused efforts to address these inequalities.

While a New Zealand Institute of Economic Research report (NZEIR 2003) has noted the lack of a comprehensive national database on the development and progress of Maori health providers over the past decade, a number of success stories have been recorded. These are providers who have developed projects based on community and Maori development principles that address the key aims of the PHCS (see Robinson and Blaiklock 2003, Earp and Matheson 2004). The policy and structural changes brought about by the PHCS have for the most part been welcomed by Maori health providers as they closely resemble those that these providers have adhered of aspired to. The frameworks detailed in He Korowai Oranga: Maori Health Strategy (King and Turia 2002a) have further validated Maori health providers' whanau-based holistic models of health care provision and provided a blueprint for mainstream services for Maori. Taking into account the Treaty of Waitangi principles of partnership, participation and protection, it...