|Implemented in this survey?|
The New Zealand government has introduced a new system of health targets with a view to focusing the energy of the health sector towards the achievement of a limited number of strategic priorities. The ten targets chosen include process targets over which District Health Boards have some control, and intermediate health outcome targets which require collaborative action with a wide range of stakeholders. Currently, no incentives are attached to the achievement of the ten targets.
A system of ten health targets has been introduced. The purpose is to provide a tighter strategic focus for the publicly-funded health sector in New Zealand. The targets are part of a broader government strategy which sets 'a direction that is designed to establish clear and manageable priorities, improve performance management systems, and increase collaboration within the health sector' (Office of the Minister of Health, 2007).
Health targets not (yet?) tied to incentives
As of late 2007, the health targets framework is not tied to identifiable incentives. District Health Boards (DHBs) will be required to report on progress towards their own specified targets (which vary from DHB to DHB and are published in government-mandated planning documents). According to the policy paper, '(a)t this point, there have been no specific incentives associated with the targets; instead the sector will use a collaborative approach to problem-solving and working together to support achievement of the target. However as the programme unfolds, the Ministry and the sector will assess whether more should be done to support improved performance'. As such, it is possible that stronger incentives may be introduced in the future. Any move towards stronger incentives, however, would only be applicable to some of the targets, particularly those over which the Ministry and the DHB have more direct control and influence.
There are three different types of targets.
The ten health targets are:
Where appropriate, the Ministry of Health will negotiate specific targets with individual DHBs. The list of targets will be reviewed annually in order to confirm that each target continues to be important and relevant.
* "Vote Health" is the name for the share of the government budget allocated to health
A system of ten health targets aims to provide more focused strategic direction to the public health system.
There are no incentives or sanctions associated with these targets.
Ministry of Health, District Health Boards, Primary Health Organisations
|Medienpräsenz||sehr gering||sehr hoch|
The new health targets may be useful in communicating the Ministry of Health's priorities to the sector. However, at this stage there is little reason to believe that this target regime will be any more successful in gaining wider traction in the health sector than previous exercises of this nature in New Zealand and internationally. This is particularly the case given the lack of concrete incentives that are attached to this target framework.
The introduction of the new health targets framework was a consequence of an internal review of the Ministry of Health which was instigated by the incoming Director General of Health in late 2006. The review concluded that there was a need to adopt a more focused and strategic vision for the Ministry and the sector as a whole. The development of health targets reflects an incremental shift in policy building on existing population health and DHB performance monitoring regimes. The targets can also be seen as a response to growing political pressure on the government regarding waiting times for elective surgery and specialist consultation that had intensified in 2006-07.
The targets were first outlined in the Ministry of Health's 2007-10 Statement of Intent. However, in order to give the targets a higher profile in the sector, the targets were given a media release in August 2007.
The New Zealand National Health Strategy
|Implemented in this survey?|
The use of targets in the New Zealand publicly-funded health system is not new. Public health targets were monitored throughout the 1990s in annual reports. Many of the targets included in the list of ten have been used for some time. Up until 2006 the Ministry of Health also used a formal set of indicators to monitor the non-financial performance of DHBs in the Government's key priority areas. These indicators included a mix of process output and outcome indicators and varied from year to year in line with current Government priorities. DHBs had been required to set targets for each indicator in their Annual Plans and to report quarterly, 6 monthly or annually on progress towards achievement. DHBs not meeting these targets were required to submit resolution plans to the Ministry of Health.
In late 2006, an internal review of the Ministry of Health noted the lack of strategic capacity within the Ministry. This seemed particularly problematic given that District Health Boards were required by law to engage in strategic planning, with their planning documents reviewed regularly by the Ministry. The development of targeting has been strongly advocated by the incoming Director-General (Chief Executive) of the Ministry who was previously the CEO of one of the country's largest DHBs. Senior Ministry officials were keen to learn from the English NHS experience with targets, particularly the star rating system. Their justification for targeting drew on work done by Nicholas Mays (Office of the Minister of Health 2007). Mays, a British health policy expert, produced a working paper for New Zealand Treasury on the potentials and possible pitfalls of the English approach (Mays 2006). Mays recommended the use of a limited number of targets with specific objectives 'that is reasonably (not necessarily entirely) within the power of the relevant institution to influence' (p22), and that targets should be related to sanctions and rewards.
Some of the targets are consistent with Mays' recommendations that health sector organisations have it within their power to influence them. However, most of the targets do not have this characteristic, and none are tied to sanctions or rewards.
The approach of the idea is described as:
renewed: The first population health goals and targets for NZ were set in the late 1980s.
The Ministry of Health claims that the targets approach has been developed in collaboration with DHBs. While there has been no public indication of DHBs' attitudes so far, this refinement of the performance indicator regime is likely to be welcomed because it potentially streamlines the performance expectations of DHBs. One DHB chief executive with UK NHS experience has noted that it is important to avoid some of the pitfalls experienced in England with the star rating system.
Other, non-governmental stakeholders have tended to comment not on the whole package of targets, but on the particular targets that are relevant to their interests. The targets relating to childhood immunisation and diabetes have been broadly welcomed by stakeholder groups in these areas. In relation to other targets, the level of the targets have been criticised by some as inadequate (e.g. reduction in cancer waiting times), while others have questioned the capacity of DHBs to achieve their specified targets without additional resources (e.g. oral health).
|NZ Medical Association||sehr unterstützend||stark dagegen|
|Individual clinicians||sehr unterstützend||stark dagegen|
|District Health Boards||sehr unterstützend||stark dagegen|
|Consumer advocacy groups||sehr unterstützend||stark dagegen|
|NZ Medical Association||sehr groß||kein|
|Individual clinicians||sehr groß||kein|
|District Health Boards||sehr groß||kein|
|Consumer advocacy groups||sehr groß||kein|
The nature of the targets vary considerably. Six of the targets (1,2, 5, 6, 8 & 9) could be described as intermediate outcomes which require significant levels of collaboration with providers, community groups and non-government organisations. Some of these targets are less amenable to direct governmental influence and are dependent on the achievement of behavioural change over which health sector organisations have rather marginal influence (e.g nutrition, smoking). For other targets (e.g. oral health, immunisation) health workforce capacity issues are likely to be paramount. Co-operation, involvement of actors throughout the sector, particularly primary care practitioners and the Primary Health Organisations they work for, is crucial.
A review of international approaches to outcome-related targets suggested that most originated by senior politicians and/or public officials, but that successful implementation required engagement and ownership of targets by 'grass roots' providers and professionals (Wismar & Busse 2002). In most examples of target-setting reviewed by these authors, such engagement was largely absent. At this stage, the current New Zealand approach is consistent with this pattern. Three of the targets (3,4 & 7) are primarily process indicators which are more subject to control by District Health Boards. Achievement of these targets would require significant engagement of clinicians and other providers within DHBs.
The targets will be monitored through DHB quarterly performance reports.
There are good reasons to be sceptical that this health targets initiatve will be successful. Wismar & Busse suggest that 'voluntaristic' approaches to the setting and implementation of outcome-related targets are unlikely to be effective, and more concrete incentives and sanctions may be necessary. At this stage, no such incentives or sanctions are related to the outcome-related targets. However, even if such concrete incentives and sanctions are introduced later, there are significant conceptual problems in attributing success or failure in the achievement of these objectives to the actions of health sector organisations. As such, it is inherently difficult for such targets to be incorporated into accountability frameworks. It is highly unlikely that DHBs can be held strictly accountable for targets such as 'increasing the proportion of adults eating two or more servings of fruit per day to 62% or greater'.
If any move is made to tighten the framework of monitoring and accountability, it is likely to be in relation to the process targets (waiting times, mental health). Evaluations of the star rating system in the English NHS gives some support for the use of targets backed by concrete positive and negative sanctions. Performance in meeting targets improved dramatically (Mays 2006). However it remains unclear as to whether the successful meeting of targets resulted in poor performance in domains not measured, or exemplified the problem of 'hitting the target but missing the point' (Bevan & Hood 2006). 'Hard' targets are more likely to gain traction, but by their nature increase the likelihood of perverse incentives, unintended consequences and gaming. The combination of more controllable process targets and more contingent outcome targets may prove to be somewhat unstable, and it is possible that these different types of targets will be 'unbundled' in the future.
|Qualität||kaum Einfluss||starker Einfluss|
|Gerechtigkeit||System weniger gerecht||System gerechter|
|Kosteneffizienz||sehr gering||sehr hoch|
These targest are best seen as an incremental development which are likely to have limited impact initially either on health services or on health outcomes. However, they may be further developed in the future to drive more significant changes in some areas.
Centre for Health Services Research and Policy