How to Organize Public Health?

The Health of the People By David Skegg 144 pp.; $14.99 Wellington, New Zealand: BWB Texts; 2019 (softcover) ISBN-13: 9781988545585

What is the best way to organize public health? Where in the apparatus of democratic government should it be placed? What are the fundamental ingredients of public health success? There is no shortage, one might think, of experience to draw on, given the great variety of public health systems around the world. However, I know of few scholarly accounts of what works well and what does not.

The Health of the People is a book that helps to fill the gap. It is a concise and passionately argued account of the rise and fall of the New Zealand Public Health Commission (PHC) written by the man who was chair of the board of the commission, Professor Sir David Skegg.

The PHC was established by the New Zealand government in 1992 to improve and protect public health. It was a crown entity, meaning a public organization that is not under the direct control of ministers (as is a government department). The commission was a novel and ambitious undertaking; it was also short lived.

First, some background to the story. The population of New Zealand (almost 5 million) is two thirds that of Long Island, New York, and the country sits so deeply in the bottom right-hand corner of world maps that it is sometimes left off altogether.¹ By international standards, its politics would for the most part be described as socially progressive.² New Zealand was an early mover, for example, in granting women the vote, introducing comprehensive child health care, banning nuclear weapons, and legalizing gay marriage. But there is also a history in New Zealand, a highly centralized democracy without a formal, written constitution or a parliamentary house of review, of political volatility, including raising and lowering of trade barriers, introduction and withdrawal of comprehensive welfare benefits, and transfers of significant assets into and out of state ownership.³

Most disruptive, in its effects on the economy, social welfare, and the health of the population, was the neo-liberal “revolution” of the 1980s and 1990s. This followed a general election won by Labor, traditionally the party of the left. But in power the government, led by David Lange, departed radically from positions taken by its predecessors on almost every fundamental question of social policy. What caused the rupture is disputed still; the dire state of the national economy and the popularity at the time of neo-liberal philosophies were likely part of the explanation.

The consequences were titanic. Political scientists Jonathan Boston and Chris Eichbaum wrote that “the sheer scope, scale, and—not least—the pace of policy changes [were] breathtaking. Virtually every significant area of public policy . . . was refashioned or reengineered.”^4(p373)

In health, the biggest changes occurred after 1991. When the director-general of the Department of Health presented his postelection briefing in that year to the incoming minister (this time in a right-wing national government), he was told “I have two briefings and I much prefer the Treasury’s to yours” (personal communication). The director-general resigned shortly afterward.

The following were the touchstones of the health reforms that ensued: market forces, competition, and efficiency. A committee was established by the government to determine the core health services that should be paid for with public money. All hospital services were provided by for-profit “crown health enterprises” that competed for contracts held by regional funding authorities. The Department of Health was reduced to a smaller, policy-oriented ministry, giving up to the PHC most responsibilities for public health.

What distinguished the PHC was the breadth of its remit (which included gathering and analysis of public health statistics and provision of public health services such as screening and health education to the national population), its institutional location at arm’s length from the government, and the standing of the individuals appointed to leadership positions. Notably, David Skegg, one of New Zealand’s most experienced and highly respected epidemiologists, was the chair of the board. His style was energetic and hands on, and he worked effectively with the chief executive, Gillian Durham. What also stands out in this story, unfortunately, is that despite the promise of the PHC, its life was short. Within three years the commission was terminated, and its functions returned to the Ministry of Health.

What went wrong? Skegg was in the thick of the action and so is well placed to describe the turbulence within the government and the public service at the time and the heavy lobbying by interest groups, both for and against the commission. His conclusion is that the PHC fell as a result of interventions by powerful commercial interests (tobacco, food companies, and alcohol, in particular), rivalries with other government departments (especially the Ministry of Health), and bad luck on the political front. The minister who established the PHC, Simon Upton, with whom one gets the impression Skegg enjoyed good rapport, did not stay long, and Upton was succeeded by politicians without enthusiasm for the venture.

Others have suggested that the seeds of the downfall of the PHC were sown at the time it was established.⁵ Upton had lofty ideas about the virtues of small government (“disaggregated, decentralized, and diverse” was his prescription). But it was soon apparent that a decentralized and diverse arrangement for public health could make life difficult for ministers of health who had given up a large measure of control but remained accountable for all that happened in their portfolio. The PHC, owing to its prominence and the forthright positions it took on issues such as alcohol pricing, made health less governable than it had been previously.

It may be true that the lobbying by the alcohol, tobacco, and food industries was an immediate cause of the commission’s demise, but there was a deeper problem. The PHC was given an immensely difficult task: to act simultaneously as a public health advocate and an effective policy machine. The commission was required to be accountable both to its professional constituency (as a thought leader and representative of public health concerns) and to political stakeholders (ministers, public service mandarins, and policy influencers more broadly). And it is apparent that this tension within public health institutions between the roles of “outsider” and “insider,” even if well managed, may be very risky when the political climate turns sour.⁶

So what is the best way to organize public health? Skegg offers some alternatives, relevant to the New Zealand context, that divide functions between a close-to-the-minister government department and a more distant crown entity. But I suggest that the search for public health success is more complicated than redrawing organizational maps. My reading of Skegg’s excellent book is that we must prepare for tensions and difficulties, whatever the configuration of the bureaucracy and whoever the actors of the day, because of the nature of public health and the demands of open government.

Rather than the optimum organizational map, it may helpful to think of public health as an ecosystem. Ecologists have pointed out that simple systems, apparently highly efficient, often outperform alternatives when conditions are stable. But if the external environment changes frequently and unpredictably, then complexity and diversity are important assets.⁷ In this light, we might conclude that the organization of public health should value flexibility more highly than efficiency. We might conclude that public health is best placed to withstand threats and exploit opportunities if some redundancy is built in, if diverse response capacities are protected, if there is high interconnectedness within and beyond the public health sector, if public health bodies have the ability to self-organize, and if culture, practice, and structure give the highest priority of all to learning.