How did New Zealand's regional District Health Board groupings work to improve service integration and health outcomes: a realist evaluation.

OBJECTIVES: In Aotearoa New Zealand (NZ), integration across the healthcare continuum has been a key approach to strengthening the health system and improving health outcomes. A key example has been four regional District Health Board (DHB) groupings, which, from 2011 to 2022, required the country's 20 DHBs to work together regionally. This research explores how this initiative functioned, examining how, for whom and in what circumstances regional DHB groupings worked to deliver improvements in system integration and health outcomes and equity. DESIGN: We used a realist-informed evaluation study design. We used documentary analysis to develop programme logic models to describe the context, structure, capabilities, implementation activities and impact of each of the four regional groupings and then conducted interviews with stakeholders. We developed a generalised context-mechanisms-outcomes model, identifying key commonalities explaining how regional work 'worked' across NZ while noting important regional differences. SETTING: NZ's four regional DHB groupings. PARTICIPANTS: Forty-nine stakeholders from across the four regional groupings. These included regional DHB governance groups and coordinating regional agencies, DHB senior leadership, Maori and Pasifika leadership and lead clinicians for regional work streams. RESULTS: Regional DHB working was layered on top of an already complex DHB environment. Organisational heterogeneity and tensions between local and regional priorities were key contextual factors. In response, regional DHB groupings leveraged a combination of 'hard' policy and planning processes, as well as 'soft', relationship-based mechanisms, aiming to improve system integration, population health outcomes and health equity. CONCLUSION: The complexity of DHB regional working meant that success hinged on building relationships, leadership and trust, alongside robust planning and process mechanisms. As NZ reorients its health system towards a more centralised model underpinned by collaborations between local providers, our findings point to a need to align policy expectations and foster environments that support connection and collegiality across the health system.

Transparency in Healthcare Reporting: The Case of External Contractors and Consultants in New Zealand's Healthcare System.

This study investigates the quality of reporting around the spending related to the use of external consultant and contractors in New Zealand's 20 District Health Boards (DHBs). We make use of the publicly available annual reviews conducted by the New Zealand Parliament Health Select Committee (HSC) as well as DHB data which were retrieved using Official Information Act (OIA) requests. The quality of reporting was judged on the differences and discrepancies observed in the HSC reports each year as well as the DHB internal data. Perhaps, unsurprisingly, total spending on external consultants and contractors has been increasing over the years while the quality of reporting has been decreasing. Our analysis highlighted a number of quality issues-mistakes, discrepancies and an overall lack of standardised reporting in almost all of the DHBs. Some of these discrepancies included failure to provide information required by the HSC, differences in yearly total amounts in consecutive reports and differences between information provided to the HSC and to the authors of this article. It is hoped that this research and the prospective areas for improvement highlighted here are used as a guide to improve the quality of healthcare financial reporting.

Private choices, public costs: Evaluating cost-shifting between private and public health sectors in New Zealand.

New Zealand's dual public-private health system allows individuals to purchase health services from the private sector rather than relying solely upon publicly-funded services. However, financial boundaries between the public and private sectors are not well defined and patients receiving privately-funded care may subsequently seek follow-up care within the public health system, in effect shifting costs to the public sector. This study evaluates this phenomenon, examining whether cost-shifting between the private and public hospital systems is a significant issue in New Zealand. We used inpatient discharge data from 2013/14 to identify private events with a subsequent admission to a public hospital within seven days of discharge. We examined the frequency of subsequent public admissions, the demographic and clinical characteristics of the patients and estimated the direct costs of inpatient care incurred by the public health system. Approximately 2% of private inpatient events had a subsequent admission to a public hospital. Overall, the costs to the public system amounted to NZ$11.5 million, with a median cost of NZ$2800. At least a third of subsequent admissions were related to complications of a medical procedure. Although only a small proportion of private events had a subsequent public admission, the public health system incurred significant costs, highlighting the need for greater understanding and discussion around the interface between the public and private health systems.

Protocol for a mixed methods realist evaluation of regional District Health Board groupings in New Zealand.

INTRODUCTION: Achieving effective integration of healthcare across primary, secondary and tertiary care is a key goal of the New Zealand (NZ) Health Strategy. NZ's regional District Health Board (DHB) groupings are fundamental to delivering integration, bringing the country's 20 DHBs together into four groups to collaboratively plan, fund and deliver health services within their defined geographical regions. This research aims to examine how, for whom and in what circumstances the regional DHB groupings work to improve health service integration, healthcare quality, health outcomes and health equity, particularly for Maori and Pacific peoples. METHODS AND ANALYSIS: This research uses a mixed methods realist evaluation design. It comprises three linked studies: (1) formulating initial programme theory (IPT) through developing programme logic models to describe regional DHB working; (2) empirically testing IPT through both a qualitative process evaluation of regional DHB working using a case study design; and (3) a quantitative analysis of the impact that DHB regional groupings may have on service integration, health outcomes, health equity and costs. The findings of these three studies will allow refinement of the IPT and should lead to a programme theory which will explain how, for whom and in what circumstances regional DHB groupings improve service integration, health outcomes and health equity in NZ. ETHICS AND DISSEMINATION: The University of Otago Human Ethics Committee has approved this study. The embedding of a clinician researcher within a participating regional DHB grouping has facilitated research coproduction, the research has been jointly conceived and designed and will be jointly evaluated and disseminated by researchers and practitioners. Uptake of the research findings by other key groups including policymakers, Maori providers and communities and Pacific providers and communities will be supported through key strategic relationships and dissemination activities. Academic dissemination will occur through publication and conference presentations.

A media content analysis of New Zealand's district health board Population-Based Funding Formula.

AIM: The Population-Based Funding Formula (PBFF) has a significant impact on health funding distribution between New Zealand's 20 district health boards (DHBs) yet is subject to little independent oversight or public scrutiny. There has been widespread dissatisfaction among DHBs with the allocation process; however, there are limited formal avenues available for DHBs and the public to discuss the PBFF. As such, the news media has become a key platform for voicing concerns. This study aims to gain a better understanding of how the PBFF is portrayed in the news media and of perceptions of funding allocations across the country. METHOD: We conducted thematic analyses of 487 newspaper articles about the PBFF, published over 13 years from 2003-2016. We then identified trends in the data. RESULTS: Typically presented in a negative light, the PBFF was commonly framed against a background of financial struggle and resultant impacts on health services and staff. The effect of factors driving DHB allocations and the PBFF process itself were also key themes. There were significant regional and temporal variations in reporting volume, with most articles focusing on South Island DHBs and occurring during the introduction of the PBFF and at the time of the most recent review. CONCLUSIONS: The findings suggest general discontent with the PBFF model across the DHB sector and a sense that the PBFF has failed to address various challenges facing DHBs. The geographic imbalance in reporting volume suggests that frustration with the PBFF is particularly keenly felt in the South Island. Although the PBFF is a lightning rod for frustrations over limited health funding, the findings point to the need to improve transparency and dialogue around the formula and to monitor of the impact of PBFF allocations throughout the country.

The role, costs and value for money of external consultancies in the health sector: A study of New Zealand's District Health Boards.

Public spending on external consultancies, particularly within the health sector, is highly controversial in many countries. Yet, despite the apparently large sums of money involved, there is little international analysis surrounding the scope of activities of consultants, meaning there is little understanding of how much is spent, for what purpose and with what result. This paper examines spending on external consultancies in each of New Zealand's 20 District Health Boards (DHB). Using evidence obtained from DHBs, it provides an insight into the cost and activities of consultants within the New Zealand health sector, the policies behind their engagement and the processes in place to ensure value for money. It finds that DHB spending on external consultants is substantial, at $NZ10-60 million annually. However, few DHBs had policies governing when consultants should be engaged and many were unable to easily identify the extent or purpose of consultancies within their organisation, making it difficult to derive an accurate picture of consultant activity throughout the DHB sector. Policies surrounding value for money were uncommon and, where present, were rarely applied. Given the large sums being spent by New Zealand's DHBs, and assuming expenditure is similar in other health systems, our findings point to the need for greater accountability for expenditure and better evidence of value for money of consultancies within publicly funded health systems.

Change, Connectivity, and Challenge: Exploring the Role of Health Technology in Shaping Health Care for Aging Populations in Asia Pacific.

Aflthough the rapid increase in population aging observed across the globe poses significant challenges to the sustainability of health systems it has been paralleled by an exponential growth in health technologies. This article reviews the literature surrounding health technologies and explores how the future of aging and health care could be shaped by health technologies, with a particular focus on the Asia Pacific region. It shows that the field is wide in scope. The current expansion of information and communication technologies have brought a growing capacity to support health care, while future technology applications, such as robotics and 3D printing, offer a range of potential benefits to elderly populations. However, the uptake and level of development of health technologies varies widely throughout the region. Governments have begun developing frameworks to guide the implementation and monitoring of health technologies. However, a dearth of robust, evaluative studies, combined with the rapidly evolving nature of health technologies, present policy makers with a range of policy and implementation challenges, including issues surrounding infrastructure, funding, and the acceptability of technologies among older users. As health technologies play an increasingly pivotal part in health systems, there is a need to create robust mechanisms for ongoing assessment of health technology development.

Cost-Effectiveness of Surveillance for Bloodstream Infections for Sepsis Management in Low-Resource Settings.

Bacterial sepsis is a leading cause of mortality among febrile patients in low- and middle-income countries, but blood culture services are not widely available. Consequently, empiric antimicrobial management of suspected bloodstream infection is based on generic guidelines that are rarely informed by local data on etiology and patterns of antimicrobial resistance. To evaluate the cost-effectiveness of surveillance for bloodstream infections to inform empiric management of suspected sepsis in low-resource areas, we compared costs and outcomes of generic antimicrobial management with management informed by local data on etiology and patterns of antimicrobial resistance. We applied a decision tree model to a hypothetical population of febrile patients presenting at the district hospital level in Africa. We found that the evidence-based regimen saved 534 more lives per 100,000 patients at an additional cost of $25.35 per patient, resulting in an incremental cost-effectiveness ratio of $4,739. This ratio compares favorably to standard cost-effectiveness thresholds, but should ultimately be compared with other policy-relevant alternatives to determine whether routine surveillance for bloodstream infections is a cost-effective strategy in the African context.

Performance Requirements to Achieve Cost-Effectiveness of Point-of-Care Tests for Sepsis Among Patients with Febrile Illness in Low-Resource Settings.

Bacterial sepsis is an important cause of mortality in low- and middle-income countries, yet distinguishing patients with sepsis from those with other illnesses remains a challenge. Currently, management decisions are based on clinical assessment using algorithms such as Integrated Management of Adolescent and Adult Illness. Efforts to develop and evaluate point-of-care tests (POCTs) for sepsis to guide decisions on the use of antimicrobials are underway. To establish the minimum performance characteristics of such a test, we varied the characteristics of a hypothetical POCT for sepsis required for it to be cost-effective and applied a decision tree model to a population of febrile patients presenting at the district hospital level in a low-resource setting. We used a case fatality probability of 20% for appropriately treated sepsis and of 50% for inappropriately treated sepsis. On the basis of clinical assessment for sepsis with established sensitivity of 0.83 and specificity of 0.62, we found that a POCT for sepsis with a sensitivity of 0.83 and a specificity of 0.94 was cost-effective, resulting in parity in survival but costing $1.14 less per live saved. A POCT with accuracy equivalent to the best malaria rapid diagnostic test was cheaper and more effective than clinical assessment.

How are population-based funding formulae for healthcare composed? A comparative analysis of seven models.

BACKGROUND: Population-based funding formulae act as an important means of promoting equitable health funding structures. To evaluate how policy makers in different jurisdictions construct health funding formulae and build an understanding of contextual influences underpinning formula construction we carried out a comparative analysis of key components of funding formulae across seven high-income and predominantly publically financed health systems: New Zealand, England, Scotland, the Netherlands, the state of New South Wales in Australia, the Canadian province of Ontario, and the city of Stockholm, Sweden. METHODS: Core components from each formula were summarised and key similarities and differences evaluated from a compositional perspective. We categorised approaches to constructing funding formulae under three main themes: identifying factors which predict differential need amongst populations; adjusting for cost factors outside of needs factors; and engaging in normative correction of allocations for 'unmet' need. RESULTS: We found significant congruence in the factors used to guide need and cost adjustments. However, there is considerable variation in interpretation and implementation of these factors. CONCLUSION: Despite broadly similar frameworks, there are distinct differences in the composition of the formulae across the seven health systems. Ultimately, the development of funding formulae is a dynamic process, subject to availability of data reflecting health needs, the influence of wider socio-political objectives and health system determinants.

How are New Zealand's District Health Boards funded and does it matter if we can't tell?

In 2011 the Population Based Funding Formula (PBFF) was used to distribute a $9 billion share of Vote Health amongst District Health Boards (DHBs), making it one of the single largest determinants of the allocation of public funds and exerting considerable influence on the healthcare sector. However, there is minimal public information available regarding the methods used in the PBFF and, consequently, the process of determining DHB allocations. We sought to investigate how the PBFF works and found that no comprehensive description of the process in its entirety has ever been produced. In light of this, based on information we obtained from the Ministry of Health, we have compiled our own version of how we believe the PBFF allocations are determined. This article summarises our findings and includes an example calculation of the inpatient cost weights to illustrate our understanding of the process. Our hope is that this article will improve understanding and stimulate debate on the PBFF as well as highlight the need for greater transparency around the funding process.