The NZ Health System
The NZ health system is predominantly funded from general taxation. At the time of the research, Manatū Hauora had overall leadership of the health and disability system that included policymaking, management, and monitoring of health status, along with some purchasing/commissioning responsibilities (e.g., public health, well child, maternity, and ambulance services). Publicly financed health care was delivered through 20 DHBs, who oversaw health services in their districts. Most government health funding was distributed to DHBs using a weighted population-based funding formula (14). DHBs delivered a large range of services themselves (e.g., hospital and hospital-related community services) and purchased/commissioned a range of services from for-profit and not-for-profit privately owned providers (e.g., primary healthcare, home care and residential rest home care).
PHOs are not-for-profit meso-layer organisations that were funded by DHBs, using a weighted capitation formula, to provide comprehensive primary care services through their member general practices. General practice teams provide the first point of contact in the health system and are gatekeepers to other primary care services (e.g., medicines, laboratory tests), secondary care and some community services.
Citizens choose the general practice they enrol with, and general practices choose the PHO they become members of (15). PHOs pass on funding for first level services to their member general practices using the same weighted capitation formula that the DHBs use to fund PHOs. The funding arrangements in NZ means that general practices retain the right to charge co-payments to access primary care services. Fees are set by general practices with limited rules around frequency of increases and the maximum annual percentage increase as agreed with their contracting PHO and DHB (15). The co-payment system remains in place today.
Māori are the indigenous population of NZ. The British Crown and Māori rangatira (chiefs) signed te Tiriti o Waitangi (the Treaty of Waitangi) to live together under a common set of laws and agreements (16). Under te Tiriti o Waitangi (te Tiriti) principles, Manatū Hauora, as a Crown agent, has responsibility to work together with iwi (Māori tribe), hapū (sub-tribe), whānau (family or extended family) and Māori to plan, develop, and deliver health and disability services to ensure Māori receive equitable health care and have equitable health outcomes as pākehā (New Zealanders of European descent) while protecting Māori cultural concepts, values and practices (16, 17).
The NZ Burden of Diseases study shows that New Zealanders’ health is improving, with recent increases in life and health expectancy (18). However, NZ still has high health loss from coronary heart disease, chronic obstructive pulmonary disease, chronic kidney disease, bowel cancer, self-harm, and musculoskeletal disorders. Health inequities persist between genders, generations, and ethnic and socio-economic groups (18, 19). Health conditions that are both preventable and amenable to timely medical interventions through equitable access to health services make a significant contribution to the lower life expectancy for Māori and Pacific populations. Nearly half of all premature deaths in Pacific (47.3%) and over half of all deaths in Māori (53%) have an avoidable cause compared to under a quarter of deaths (23.2%) among non-Māori non-Pacific populations (20).
The relationship between Māori and the Crown is one of continued negotiation. Any LST initiative needs to demonstrate compliance with te Tiriti, reduce health inequities and improve health outcomes for Māori.
There have been national policies and directions to promote changes and improvement in the system, with a desire for health services to be patient-centred, high quality, co-ordinated, integrated, and equitable. This has included the introduction of national initiatives such as the NZ Triple Aim (21), the requirement for DHBs and PHOs to form Alliances to enhance integration of hospital and primary care (22), and national strategies such as the NZ Health Strategy (23), the Primary Health Care Strategy (24), and He Korowai Oranga and Whakamaua (Māori Health Strategies) (17).
Despite three decades of policy initiatives to improve integration of health care, scholars and reviewers regularly conclude that the delivery of health care remains fragmented and focused on institutional arrangements (25–28). The governance and institutional arrangements that separate service delivery of hospital, primary and community services, and the interests of powerful professional groups, have led to each service or group looking after their own interests and those of the patients in their service or speciality; and not the broader interests of patients and the population perspective (26, 29, 30).
The NZ health system has undergone a significant reform in 2022 that disestablished 20 DHBs and established two new national agencies: Te Whatu Ora - Health New Zealand and Te Aka Whai Ora - Māori Health Authority. Te Whatu Ora replaced DHBs and oversees the planning, funding, and delivery of public health services. Te Aka Whai Ora advises the government on all aspects of Māori health policy, monitors and reports on Māori health outcomes, partners with other organisations at all levels to integrate te Tiriti principles into policy, planning and service delivery, and strengthens the Māori workforce. Manatū Hauora remains the chief steward of the health system, responsible for policymaking and monitoring performance of the two new agencies. The intent of the reforms was to reduce variation in health care delivery and outcomes, increase efficiency and effectiveness by replacing 20 DHBs with a single national agency, and to ensure access to equitable health services and equitable health outcomes for Māori and other priority population groups (31).
Approach and design
This research was informed by the realist logic of enquiry, nested within the macro framing of complex adaptive systems.
A complex adaptive system is an open system with blurred boundaries, which has a large number of agents who can simultaneously be members of several sub-systems, subject to change (3, 32). In a complex adaptive system relationships, connections and interactions between system agents create feedback loops. These feedback loops influence the behaviours of agents in the system, causing them to learn, adapt and create further feedback loops. Future interactions cannot be predicted reliably from past interactions; history cannot be undone, but history influences present interactions (32, 33). Outcomes from programmes or transformation initiatives in a complex adaptive system are non-linear, therefore a focus on interactions between sub-systems and the influence of contexts is required to understand how the system works.
Our research questions centred on gaining a deeper understanding of how the LST initiative worked in different contexts, so a realist research design, as developed by Pawson and Tilley (34), was chosen to further shape this research. The realist approach offers a framework to uncover the reasoning of health system agents and the influence of social and cultural conditions in which LST initiatives are implemented. We followed a logic of enquiry in which outcomes follow from mechanisms acting in the contexts of the system (34). Following the tenets of this approach we adopted methods to test and refine programme theories to understand how mechanisms that operate according to context influence programme outcomes (34–37).
Mechanisms are underlying, unseen processes that exist in a system and influence outcomes depending on the circumstances or contexts. Mechanisms cannot be observed using methods to determine programme outcomes. They exist as part of a whole system, are triggered by contextual factors, are explanatory, have empirical content and are testable (38–40). Mechanisms can be either positive or negative, it is necessary to understand both to create the environment for an intervention to produce the desired outcomes.
Contexts describe the organisational, social, cultural and political conditions that trigger the mechanisms, which then determine the programme outcomes (38, 40). Each context in which a programme is implemented, for example using a top-down or a bottom-up approach for LST initiatives, triggers a different set of mechanisms which influences whether key outcomes (desired changes) are achieved. Context can be both an enabler and a barrier. A context that is enabling in one place can be a barrier in another owing to local needs and capability.
Mid-range theories in the form of context-mechanism-outcome (CMO) configurations explain what are the mechanisms that explain how and why reality unfolds as it does in a particular context or what works for whom under what circumstances and why (34). Mid-range theories are essential for realist research (34). They guide us to look for CMOs, in particular the mechanisms, as these are not directly observable (41). In this research, CMOs offer a way to build on the lessons of the SLM programme and to test theories with a wide range of participants from across the health system (senior leaders to frontline staff).
Data sources and analysis
The research was conducted between November 2018 and December 2019 and included five phases.
Phase 1 – Theory gleaning. The insights and knowledge from implementation of the SLM programme was used to create initial theories. This included identifying a list of key elements that supported the implementation of the SLM programme (listed in the first column of Table 2), and initial propositions on how these elements worked in different contexts to influence successful implementation. For this research, successful implementation included a robust evidence-based planning process, full implementation of the agreed plan, and continuous reflective learning. The key elements and propositions were gained by documenting first-hand insights and knowledge of two authors (KMS and PBJ) involved in the development and implementation of the SLM programme and informal conversations with those involved in the implementation of the programme.
Phase 2 – Literature review. An iterative review of published and grey literature was undertaken at all research phases. This enabled the research to be flexible and respond to emerging findings. First, a broad range of keywords were used to search published literature using keywords in the OVID and PUBMED databases relating to performance, governance, accountability, transformation and measuring quality improvement. The search was limited to English language from 2008 to 2018. Second, more keywords were used to search literature on systems and complexity theories and their application in health systems world-wide and LST initiatives in the health system. This search included using Google and visiting known quality improvement websites in the United States, United Kingdom, Canada, Australia, and NZ. Third, literature review was used to identify published LST initiatives in sectors other than health. Finally, a continuous snowball approach was used to identify further relevant published and grey literature. This included checking reference lists of previously identified literature, reviewing citation lists and reviewing newsletters from research institutes. The evidence from this phase was used to refine the list of key elements that support successful implementation of LST initiatives and to further identify contexts and mechanisms that influence it.
Phase 3 – Interviews. Purposeful sampling technique was used to recruit senior system leaders for interviews (n = 12). Participants were information rich, usually in charge of initiating and supporting the implementation of LST initiatives and making decisions relating to funding and resource allocations so could provide a view on leading LST initiatives in a complex system. Table 1 shows the profile of interview participants. Seven pre-determined questions ranging from semi-structured, structured prompts and open-ended conversations were used. Written consent was obtained for all interviews. For each element, participants were read out the description of the element and were then asked to rate the extent that they agreed or disagreed with the element being necessary to increase the chances of success with implementation of LST initiatives. Participants used a five-point Likert scale (strongly disagree, disagree, neutral, agree, and strongly agree) to rate the element. In some instances, participants chose to explain their rating, in others they did not. Once participants had finished rating the elements, they were asked to identify additional elements. The teacher-learner method was used to test and uncover CMO theories. Participants were introduced to our initial propositions and then switched to learner to seek their perspective. This allowed us to test our initial theories and uncover new ones. As interviews progressed, theories discovered from earlier interviews were also tested.
Phase 4 – Workshop. The aim of the workshop was to use the knowledge of those working in the NZ health system to refine the key elements needed to support the successful implementation of LST initiatives and to identify the contexts and mechanisms that influence these initiatives. Participants (n = 10) were senior leaders and clinicians who were involved in the design or the implementation of the SLM programme, those who had significant experience and knowledge about the programme, and those charged with making major strategic decisions about where effort goes towards supporting these initiatives in their organisations. Other variables that were considered in the selection of the participants were: recognised leaders in the health system; Māori, equity, rural, nursing, and allied health perspectives; and advocates of service users who understood the complexity of the health system. Participation in the workshop was confirmed once written consent was received from the participant and their Chief Executive.
The workshop was facilitated by one of the authors (PBJ, the SLM programme clinical lead) who had led the co-development of the SLM programme and was a practising clinician who therefore had the relevant skills, subject matter expertise and credibility to elicit information from participants about what worked and what did not work with the implementation of the SLM programme.
The workshop contained three sessions to reach consensus on the key elements that support LST initiatives, to define and describe the outcomes for the key elements identified, and to test and uncover contexts and mechanisms that influenced the successful implementation of LST initiatives.
Data from the workshop was collected and analysed in real-time throughout the workshop. Data from previous sessions informed subsequent sessions of the workshop. Parts of the workshop were audio recorded with participants’ written consent. NVivo computer software programme was used to group key thematic groups of texts from the transcripts and coded deductively.
Table 1
Interviewee Profile |
Health consultant and involved in the development of the SLM programme |
Academic and health researcher in NZ |
Health consultant and previous Chief Executive of a DHB |
Health consultant and direct experience in the NZ health system |
Māori clinician and involved in the development of the SLM programme |
Clinician and leader of an LST initiative in Scotland |
Health consultant and direct experience in the NZ health system and NHS |
Health researcher of LST initiatives in complex adaptive systems |
Clinician and leader of an LST initiative in Australia |
Managing director – construction company in NZ |
Technology and risk manager – NZ Bank |
Strategic management consultant – NZ, Australia, and UK |
Phase 5 – Online survey. The aim of the survey was to consolidate the key elements and further test our initial propositions and perspectives gained from interviews and workshop with those involved in the implementation of the SLM programme in DHBs and PHOs. These participants had an inside knowledge and experience of what influenced the successful implementation of the SLM programme in their districts.
Fifty-one respondents from DHBs and PHOs participated in the online survey. They were made up of health care professionals (n = 8), those in management or leadership roles (n = 33), and others such as quality improvement leaders and analysts (n = 10).
The survey instrument included 10 key elements and refined initial CMO theories consolidated from the interviews and the workshop. Participants were asked their level of agreement on key elements and refined propositions using a five-point Likert scale (strongly disagree, disagree, neither disagree nor agree, agree, and strongly agree). Using open-ended questions, participants were then asked to identify further contexts and mechanisms that influenced the implementation of the SLM programme in their district.
Qualtrics survey software was used to analyse the survey data. NVivo computer software programme was used to group key thematic groups of qualitative data from the free text comment fields.