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December 2019 (Volume 97)
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The New Zealand Government this year delivered a wellbeing budget focused on five priority areas—addressing mental health and addiction, improving child wellbeing, supporting Māori and Pasifika aspirations, thriving in a digital age, and transforming the economy through transition to a low-emission sustainable economy.1 This novel approach has generated global interest and commentary, including in this journal.2 From a health perspective, a centerpiece of the Wellbeing Budget was a substantial investment in a range of mental health and addiction initiatives, largely in response to the report of a Government-commissioned inquiry.3
The key features of the Wellbeing Budget that distinguish it from a typical budget process (either in New Zealand or elsewhere) are the determination of the focus areas a priori based on social, economic, environmental, and cultural considerations; input from government chief science advisors to identify where New Zealand could and should be doing better; the requirement for agencies and government ministers to work together and submit joint proposals; and the (legally mandated) publication of a child poverty report as part of the supporting documentation.
Notably, sitting behind the Wellbeing Budget is a Living Standards Framework developed by the New Zealand Treasury over the past eight years. This framework explicitly considers “four capitals”—human, social, natural, and physical/financial—and identifies 12 wellbeing domains, one of which is health. Wellbeing is measured and reported through a suite of wellbeing indicators.
The wellbeing framework adopted in New Zealand aligns strongly with public health approaches, notably the focus on broader determinants of health and equity. Encouragingly, health outcomes are being considered and contributed to by a range of government agencies. For example, the government’s budget investment in mental health and addiction services is not confined to the health system but also supports significant initiatives in the justice and education systems.
A wellbeing approach is likely to support improved health outcomes in New Zealand, in particular for groups with poorer health status, notably Māori, Pasifika, and other people who experience high levels of deprivation. It is important to note that Māori experience poorer health and social outcomes than non-Māori in New Zealand in just about every wellbeing domain. The obligation to improve outcomes for Māori is inherent in the 1840 Treaty of Waitangi between the Crown and Māori.4 There is renewed commitment to delivering on this obligation in the health sector, given the unacceptable seven-year life expectancy gap between Māori and non-Māori and the strong evidence that the health care system does not deliver fairly for Māori.
Importantly, the notion of wellbeing also challenges people working in public health and across the health care system to think differently in three ways.
First, the wellbeing domains in the Living Standards Framework include but do not privilege health. The so-called determinants of health are arguably better described as determinants of wellbeing—for individuals, families and communities. In his Wellbeing Budget speech, the New Zealand Minister of Finance defines wellbeing as “when people are able to lead fulfilling lives which have purpose and meaning to them.”5 The challenge (and opportunity) here is for health to embrace this broader definition and move beyond a tendency to own these domains through labeling and treating them selectively as health determinants.
Second, it is an important reminder that good health is not just an outcome (albeit a very important one) but also an enabler of broader wellbeing. Thus, a wellbeing approach imbues good health with greater sense of purpose; not just the what as described in the classic World Health Organization definition,6 but also the why: because good health helps people to lead fulfilling and meaningful lives.
Third, the consideration of wellbeing must be respectful of the aspirations of individuals, families, and communities. Those aspirations may not always align with what the health sector considers best for good health but that doesn’t mean they are wrong or inappropriate. It is a fundamental responsibility of the people working in public health and the health sector to seek the views of individuals, families, and communities in determining health policies and the provision of services. This aligns well with the move in clinical practice from asking the question, “What is the matter with you?” to asking, “What matters to you?”
This approach is being taken in implementing a central feature of the Wellbeing Budget, namely a substantial investment in primary and community mental health and addiction services. The intention is to ensure over time that services are available through a range of providers for all people experiencing mild to moderate mental health and addiction issues. The service settings will include primary care, community-based organizations, online platforms, and Māori and Pacific providers. While there will be certain requirements of all services, for example, related to availability, workforce training and oversight, and monitoring and reporting, a codesign approach is being taken to develop the service models to ensure they are accessible and effective for a range of population groups.
A particular challenge in scaling up these services is identifying and training the workforce needed to deliver them. The first investment made was to train the first tranche of workers, so-called health improvement practitioners—effectively a new workforce that has proven to be very effective in pilot programs. The government’s intention to ensure access across the wider population within four years is ambitious but the level of interest is high. Given the high prevalence of mental health issues, either alone or in combination with physical ill health among people presenting in primary care, the availability of health improvement practitioners in this setting will greatly improve the experience of both the patient and the nurse/doctor.
Finally, a wellbeing approach is a timely reminder of the fundamental importance of equity in striving to improve overall societal wellbeing. Equity has long been a core value of both public health and primary health care, and there is good reason for this: Equity in access to, experience of, and outcomes from health care is a hallmark of health care systems that deliver better outcomes for citizens and better value for money.
New Zealand’s Wellbeing Budget Invests in Population Health By Michael Mintrom
Putting Health at the Heart of National Policymaking: Learning from New Zealand By Sandro Galea and Salma M. Abdulla
Published in 2019 DOI: 10.1111/1468-0009.12428
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