Putting Health at the Heart of National Policymaking: Learning from New Zealand

Policy Forum

The state of American health leaves much to be desired. Since 2015 there has been a consecutive three-year drop in life expectancy, last seen a hundred years ago during the 1918 flu pandemic. The United States ranks last on nearly all health indicators compared to peer high-income countries despite spending more on health care. So-called diseases of despair, particularly increases in opioid addiction and suicides, are principally responsible for the rise in mortality and subsequent decline in life expectancy. Fundamentally, however, the challenge to US health has been a systematic disinvestment in the socioeconomic and physical conditions that generate health. Over the past 30 to 40 years, the United States has increasingly moved toward an individualistic ethos resulting in disinvestment in a full range of forces that shape life experiences and promote health; for example, public safety, public education, parks and recreation, the environment, stable housing, and economic opportunity. This has been accompanied by increasing investment in curative care—aiming to restore people to health once they are already sick—that is no substitute for building a society that generates health and prevents disease. This approach has contributed to an approximately five-year loss in life expectancy compared to peer countries, as well as a widening of health gaps, resulting in more than twenty-year gaps in life expectancy in counties across the United States, and, perhaps more startlingly, similar gaps within cities, with neighborhoods that are often mere miles apart having dramatically different health status. This decline in our national health comes against a backdrop of racial/ethnic inequalities that are inextricably intertwined with socioeconomic marginalization and patterns of health achievement, or lack thereof.

To rectify the current state of affairs nationally, a wholesale change in the national health conversation—one that puts health at the heart of all policymaking—is required. This argument is not new. A “Health in All Policies” approach, for example, has long been championed by the American Public Health Association as a way of ensuring that health is at the forefront of all decision-making. Health Impact Assessment (HIA) is a tool designed by the World Health Organization to allow an assessment of the health impact of disparate policy approaches—from transportation to housing, and education to taxation—as a means of guiding policymaking to generate health. Several countries have adopted approaches that have placed health front and center in their decision-making, with commensurate positive results. For example, Sweden reformulated its system through a dedicated focus on the promotion of social welfare policies that engender population health. While its shift in this direction spans decades, Sweden passed the Comprehensive Swedish Public Health Policy in 2003 seeking “to create the social conditions to ensure good health on equal terms for the entire population.”1 This focus, capitalizing on HIA to evaluate potential policy approaches, is entirely consistent with the notion that to promote the health of populations, we need to invest in the social, cultural, and political factors that promote health. It has also borne fruit; Swedish age-standardized mortality has dropped significantly over the past decades and Sweden today has one of the highest life expectancies in the world. Other efforts that have placed health at the center of the national conversation have taken place in Chile, Thailand, and Ecuador.

Now, adding to this track record is New Zealand with its recent launch of a Wellbeing Budget, an effort to align national budgetary policies with key priority areas—improving mental health, reducing child poverty, addressing inequalities faced by indigenous people, thriving in a digital age, and transitioning to a low-emission, sustainable economy—encouraging different sectors of government to dedicate resources to achieving shared goals.2 The New Zealand effort distinguishes itself from previous national efforts by using a return on investment approach. By investing in key areas of interest, New Zealand will obtain returns that make the investments worthwhile, not simply through better national wellbeing, but also economically, as better health yields social and economic dividends.

New Zealand’s Wellbeing Budget is laudable in several ways. Placing return on investment at the heart of population health improvement is consistent with a robust understanding of the principles of population health science, recognizing that prevention is far more effective at generating positive health, social, and economic outcomes than is budgetary approach that can align incentives for various governmental units, New Zealand succeeds in creating a vision of health as a national value, with potential pathways to its execution that can yield the desired ends. The eventual outcome of the New Zealand experiment remains, of course, to be seen, but its promise is sufficient to make us ask: Could such an effort help the United States emerge from its health doldrums?

There is little question that the United States trails badly on all five dimensions that are the focus of New Zealand’s efforts:

  • Nearly one in five Americans lives with a mental illness. Further, more than one-third of adults with serious mental illness are not receiving treatment and 13% of those who report forgoing mental health care cannot afford the costs. It is estimated that serious mental illness results in $193 billion in lost earnings each year in the United States.3
  • About one in seven children are born into poverty and 40% of children spend at least one year in poverty before they turn 18. Yet, in 2018, the US federal government spent only 9% of the national budget on children—a fraction of what peer countries spend. Even this relatively small budget is projected to shrink to 6.9% over the next decade.4
  • Native Americans have a life expectancy of about 5.5 years less than that of the overall US population. The suicide rate among Native Americans is about 2.5 times the national average.5 These data are not surprising given the inequalities Native Americans live through, including inadequate access to health care, higher rates of police killings, mass incarceration, and overcrowded and poor-quality housing.
  • Harnessing the power of technological advancements is perhaps the one area in which the United States is doing relatively well, ranking 4th on the Networked Readiness Index that aims to quantify the extent to which countries are thriving in the digital world. Yet, the United States trails other high-income countries when it comes to investing in education to prepare future generations for changes in the workforce due to automation.
  • The United States also lags behind in adopting policies to transition to a low-emission, sustainable economy. Until 2017, the United States, the second largest emitter of carbon dioxide, was also a leading carbon cutter. However, this progress has been slowed by recent rollbacks of the Environmental Protection Agency rules regulating emissions. For example, a recent analysis shows that, between the years 2022 and 2035, rollbacks of regulations on automobile emissions would release up to an additional 931 million metric tons of carbon dioxide.6

Is a New Zealand-style effort possible in the United States? Despite the national health slump in which we presently find ourselves, and a decades-long track record that encourages pessimism, this does not seem implausible. The US Surgeon General has launched a report on Community Health and Economic Prosperity, which aims to synthesize our understanding of the drivers of health in the country and how efforts to improve health can result in social and economic returns on our investment. While a small step forward, it represents a positive engagement with the twinned notions that our health is not as good as it should be, and that we would be much better off if we took the right steps to make it better. The broader political moment, currently in the run up to a federal election, has seen a resurgence of populist approaches that include an avowed interest in reinvesting in social and economic programs that would improve forces such as education and housing, which, in turn, would contribute to population health.

The health of the American population will not change unless we change how we talk about health and we shift our approach to investing in the foundational drivers of health. That will require that citizens demand health, a commensurately responsive public policy, and private sector engagement with the appreciation that actions that improve health also deliver bottom line returns. Optimistically, the New Zealand Wellbeing Budget—which has been received rapturously in the global conversation—could represent a catalyst, a global turning point in which countries, such as the United States, that seem to have forgotten the foundational drivers of health, reengage around these forces to the benefit of population health. That would be a welcome change indeed.

Read more in The Milbank Quarterly Policy Forum:

New Zealand’s Wellbeing Budget Invests in Population Health
By Michael Mintrom

What Does a Wellbeing Budget Mean for Health and Health Care?
By Ashley Bloomfield


  1. Chapter 1: Background to the new Swedish public health policy. Scand J Public Health. 2004;32(64 suppl):6-17. https://doi.org/10.1080/1403495041003871
  2. Mintrom M. New Zealand’s Wellbeing Budget invests in population health [published online October 24, 2019]. Milbank Q. https://doi.org/10.1111/1468-0009.12409
  3. Rabah K; Kaiser Family Foundation. What are the current costs and outcomes related to mental health and substance use disorders? Peterson-Kaiser Health System Tracker. https://www.healthsystemtracker.org/chart-collection/current-costs-outcomes-related-mental-health-substance-abuse-disorders/#item-start. Published 2017. Accessed June 25, 2019.
  4. Urban Institute. Public spending on children in five charts. https://apps.urban.org/features/public-spending-on-children/. Published 2018. Accessed June 25, 2019.
  5. US Department of Health and Human Services, Indian Health Service. Disparities Fact Sheet. https://www.ihs.gov/newsroom/factsheets/disparities/. Published 2018. Accessed June 25, 2019.
  6. Houser T, Larsen K, Larsen J, Marsters P, Pitt H. The biggest climate rollback yet? New York, NY: Rhodium Group. https://rhg.com/research/the-biggest-climate-rollback-yet/. Published 2018. Accessed June 25, 2019.

Published 2019
DOI: 10.1111/1468-0009.12410