Restructuring and hospital care: Sub-national trends, differentials, and their impacts; New Zealand from 1981

An analysis of the "nation's health" is the central concern of this study. Its genesis was a detailed, technical, time-series research on regional and ethnic differentials in health in New Zealand. But as this work progressed it became increasingly evident that the results of this more narrow analysis could make a wider contribution to the development of a knowledge-base on health trends and on the impacts of policy on these. In a sense, the analysis provides a demographic audit of health trends over the last two decades. The focus here is different from that in most other studies on restructuring of the New Zealand health system as their concern was either to review in detail the rewriting of policy per se, and attendant structural and institutional changes (Fougere 2001), or to identify how these changes relate to changes in mortality (Blakely et al. 2008). The research question reported here was, instead, to analyse the most crucial of health outcomes, „how long we live and how often we end up in hospital‟, identified in the earlier quotation, to report patterns and trends in hospital use nationally and sub-nationally over the period under review, and to determine the degrees to which various sub-populations benefited, or did not benefit, from these changes. The analysis focuses on the hospital sector in the system, but it will also show relations between this and other sectors, formal (e.g. primary health) and less formal (notably the healthcare afforded sickness and invalid beneficiaries). Thus two questions are addressed: 1. whether or not the nation‟s population health improved over the period and; 2. whether or not there was a convergence in patterns of health gain across its constituent sub-populations defined geographically and ethnically. This monograph deals with sub-national differences in health in New Zealand over a period of substantial socio-economic restructuring and associated radical changes in health policy, health systems and their related information systems (see also, Text Appendix A). It complements the recently published analysis of national ethnic trends in mortality (Blakely et al. 2004), but differs in several critical respects. That study reviewed health status by emphasising aetiologies and causes of death. In contrast, the present analysis focuses on actuarial dimensions of both mortality and morbidity and on health as measured by functional capacity rather than the disease orientated „burden of disease‟. It goes beyond health status issues to look at the system itself, to assess whether health policy outcomes were generated more through efficiency-gain (economic or service delivery, such as those resulting in a convergence sub-nationally of supply and demand effects), or through health gains, or ideally, by both. To do this, and as a by-product to analyse changes in health status and the system in an era of restructuring, innovative methodologies and composite time-series indices combining the two dimensions of a „nation‟s health‟, needing hospital care and longevity, have had to be custom-designed. To achieve this objective, the ensuing analysis is often technical, and may introduce concepts that are unfamiliar to some readers. In order to look at possible inequalities of outcome, comparisons were made between regions and ethnic groups, as well as age-groups and genders, and as a result, in places the analysis becomes rather complex