Bulletin of the World Health Organization

Primary health care the New Zealand way

In the Wairarapa region, in the south-eastern corner of New Zealand’s North Island, health officials have struck upon a novel yet effective way to treat often wary members of the local Maori population. Holly Else reports.

Many Maori perceive hospitals and general-practice surgeries as unfriendly environments and can be reluctant to seek health care at these institutions. To combat this, one of the primary health care facilities, the Te Rangimaire clinic, is located on the marae, or sacred meeting place, so that Maori feel more at ease. The clinic has two general practitioners, who are well trusted in the Maori community.

The Reverend Marie Collin, a member of the Ngati Kahungunu tribe, one of the largest Maori tribes in the Wairarapa region, speaks glowingly of the clinic at Te Rangimaire marae. She said that the service had become so popular that it was necessary to extend the hours and relocate the clinic from an old homestead on the marae to larger rooms in a new building housing the marae’s communal dining room.

Courtesy of the Wairarapa District Health Board
Dr Cath Becker examines a patient in the Te Rangimaire clinic.

“Although the doctor, Cath Becker, is of European ancestry she is culturally sensitive, understands Maori protocol and is well respected by the community. Our kaumatua (Maori elders) are very comfortable coming here,” says Collin. “The doctor knows how to handle our people and what we do differently.”

As an example she cites a relaxed attitude to appointments. “If our people are running late it is no big deal. It’s not an issue. People just arrive and take their turn.”

Clinics such as the one at Te Rangimaire are the result of a cultural shift in the way health services are delivered to Maori.

Helen Kjestrup, a member of the Primary Health Care Nursing Advisory Committee for the Wairarapa region, is helping develop relations between Maori and the Primary Health Organisation. “It has been slow, but it is happening,” she says.

To do this, she attends hui, Maori community meetings. Kjestrup believes that establishing health-care clinics in places where the Maori people feel comfortable has improved their access to health care.

New Zealand’s primary health care system has undergone dramatic changes since 2000 – changes that government officials say have already improved access to its services for Maori and other groups.

Pierre Almasy/WHO
Cardiographic examination of a Maori woman at the Wellington hospital in 1968.

The Wairarapa region, a sparsely populated agricultural valley between the Tararua mountains on the west and the Pacific Ocean on the east, can claim to have successfully implemented many of these changes.

The valley’s population is a mix of European, Maori and Pacific Islanders, whose health-care needs vary enormously. The Wairarapa Primary Health Organisation is addressing these demands by working with the different communities to address the disparities in health between the different groups.

“Primary Health Organisations are enormously different beasts,” says Joy Cooper, general manager of the Wairarapa District Health Board. “There is a huge variety of styles and sizes.”

In Masterton, one of the main towns in the valley, there is a community centre for Pacific Islanders, Cameron Community House, which local general practitioner Dr David Nixon visits for one hour a week. A primary care nurse also visits the centre for four hours a week.

Cameron Community House and Te Rangimaire are just two of the many primary health care services and facilities in the Wairarapa region; others include general-practice surgeries and hospital-based services such as community nursing. Most primary care providers are coordinated by the Wairarapa Primary Health Organisation, which is overseen by the district health board.

The Primary Health Organisations are the local structures for implementing New Zealand’s Primary Health Care Strategy that was launched in 2001. The core of the strategy is to reduce health inequalities, engage communities and improve the prevention and management of chronic illnesses.

Pierre Almasy/WHO
Medical examination of a man from the Nga Puhi tribe in 1968.

The strategy was based on the Declaration of Alma-Ata, says Dr Tim Kenealy, a senior lecturer at the Department of General Practice and Primary Care at the University of Auckland.

A series of policy and legislative reforms, which included the primary care strategy, was formulated after a change in national government in 1999. The strategy was developed after it was decided a re-emphasis on primary care could reduce the disease burden and rising costs of secondary care.

In 2002, soon after the launch of the strategy, Primary Health Organisations were established across New Zealand, each responsible for the primary health care in a region or for a group of people, sometimes with a focus on a particular ethnic group.

Today, there are 82 Primary Health Organisations across New Zealand, with an average 94% of the country’s population enrolled in one of them. Enrolment rates for Pacific Islanders are well above the average for the total population, but Maori have a lower rate of enrolment, at around 83%.

The Primary Health Organisation helps to coordinate and support the primary health care providers for its enrolled population, bringing together doctors, nurses, Maori health workers, health promotion workers, dieticians, pharmacists, physiotherapists, psychologists and midwives.

“They do not all follow the same blueprint,” says Kenealy. Innovation is encouraged, enabling some organizations to customize their services to patients.

This customization is crucial to the success of the Wairarapa Primary Health Organisation, launched in 2004 after two-and-a-half years of preparation. Its arrival has transformed relations between the seven general practices in Masterton, improving communications and fostering cooperation. Previously, the practices had been run as independent businesses. Today, although still run independently, they share information and systems.

An in-house software system enables surgeries to identify high-risk patients; those, for example, who smoke, are overweight or have high blood pressure. The information is used by a team of nurses, who then phone the often reluctant patients to recommend they come in for a check-up.

The Primary Health Organisation has a strong focus on keeping people well and in the community. Cooper uses a metaphor to explain their approach: “We have become much more focused on preventing people from falling off the cliff of poor health by building a fence at the top, rather than providing an ambulance to help people once they have fallen into ill health.”

She says that the general practices within the Primary Health Organisation now also concentrate on population health, rather than individual patients. The addition of performance indicators, which measure how each district health board and Primary Health Organisation is performing (immunization rates for example), has helped the health service providers in the Wairarapa region look up from their daily grind to the bigger picture.

Getting the primary health care providers to work together like this “has not been easy”, says Nixon. The process has been “evolutionary”.

Prior to the new strategy, the quality of New Zealand’s health services was high, but they were disjointed and “poorly integrated”, says Kenealy. There was no integration, for instance, of the multitude of health services a particular patient might need. The first key component of the strategy, the creation of the Primary Health Organisation, aimed to combat this.

Furthermore, the system only worked well if you could afford to access primary health care services, a factor that was driving health inequalities. The government hopes that the second key component of the primary care strategy, an approach known as capitation funding, can help to remove this financial barrier.

The government has invested significant new funding in Primary Health Organisations in the form of capitation funding to reduce the cost of accessing general practice services and strengthen primary health care. Under this scheme, the district health board provides funding for each Primary Health Organisation based on the number of people enrolled and not on the number of times the Primary Health Organisation provider sees patients. Similarly, District Health Boards are funded by the government for their resident population “We get a bucket of money based on our demographics,” says Cooper.

This system is “intended to provide an incentive to manage population-group risks over time”, says Kenealy. He says there is “widespread agreement that the intentions of the new system are sound” and an improvement on the past. But although access to services has improved, it is still too early to measure any improved health outcomes associated with the new system.

He believes the changes will most benefit those who currently face the highest barriers, such as cost and cultural alienation, to enjoying the benefits of primary health care services. ■