The free child health care scheme : implications for New Zealand general practice

xv, 260 leaves :ill. ; 30 cm. Includes bibliographical references.Background: The Free Child Health Care Scheme was introduced on July 1, 1997. It provided increased government subsidies for general practice consultations and fully subsidised doctor-prescribed medicines for children aged less than six years old. Thesis: The central thesis of this work is that health policy affecting general practice cannot be adequately understood by analysis from a single academic approach but requires transdisciplinary research, integrating historical, economic, epidemiologic, and policy perspectives. This thesis is examined by evaluating the Free Child Health Care Scheme and analysing its implications for New Zealand general practice. Objectives: 1. To assess the need for health policy specifically directed at young children. 2. To review the significance of fee-paying to general practice. 3. To understand the implications of the Free Child Health Care Scheme in an historical context. 4. To evaluate the Free Child Health Care Scheme using: a. A researcher-initiated plan funded by the Health Research Council (HRC). b. A project plan commissioned by the Transitional Health Authority (THA). c. A household survey commissioned by the THA. 5. To investigate the symbolic and practical implications of the Free Child Health Care Scheme for New Zealand general practice. Methods: A review of literature documenting the development of medicine, general practice, and general practice in New Zealand provided material to assess the symbolic significance of fee-paying in general practice. A further literature review established existing knowledge of the effect of changes in copayment on utilisation of health services. The researcher-initiated and THA-commissioned evaluations used a controlled before-and-after framework to examine utilisation during one-year periods before and after the start of the Free Child Health Care Scheme. The researcher-initiated evaluation used only the Dunedin RNZCGP Research Unit databases for the same purpose. All available relevant routine data sets were used for the THA evaluation. The THA-commissioned survey provided a consumer's view of the policy. Standard survey analysis techniques were used. Descriptive statistics were first computed. Bi-variable analyses tested associations between key variables and logistic regression analyses identified factors significantly associated with important outcomes. Results: Patient payments to doctors have been symbolically important in establishing the primacy of doctors' accountability to patients. The Social Security Act 1938, the Accident Compensation Corporation Act 1974, and the Free Child Health Care Scheme 1997 encapsulate the different philosophies of general practitioners and politicians regarding accountability for health services and health outcomes. The HRC and THA evaluations identified no significant impact of the Free Child Health Care Scheme on the workload of general practitioners. The household survey showed that most carers of children under six years old received the Scheme favourably. To a disproportionate degree, the Scheme failed to reach North Island families and children with private health insurance. Conclusion: Regulations affecting patient fees are of central interest to New Zealand general practitioners for reasons related to the philosophy of their profession. The Free Child Health Care Scheme had little impact on the workload of general practitioners but held many implications for the core general practice philosophy of professional independence. Evaluations of the Scheme commissioned by the THA had little utility for the organisation but were used by the Health Funding Authority and probably influenced a political decision to retain the Scheme. The household survey suggested that the Scheme may systematically exclude some of the country's most disadvantaged children