South Auckland is stamped on her heart - DHB chief takes on the biggest role in reformed health service

Fepulea’i Margie Apa, the first Pacific person to head New Zealand’s health service, grew up in south Auckland at a time of social and economic upheaval.

“The changes of the 1980s and 90s had a devastating effect on our community,” Ms Apa says.

“That kind of large-scale change had a visible, visceral impact on the people around me. People lost jobs. Families deteriorated. Mental health became an issue for many.

“That’s quite devastating for a community, and I suppose that’s been at the heart of my desire to be a public servant who is part of a system that helps reduce the impact of that kind of change on people’s health and wellbeing.

“I think that being a Pacific person is really about reflecting that I bring a particular insight to what it looks like to be in a community that experiences vulnerability, health access [issues] and poor health.”

But, when New Zealand Doctor Rata Aotearoa asked her about the significance of her pioneering achievement as the first Pacific person to top the health sector, it wasn’t this background that she spoke of first.

Ms Apa began by outlining her university qualifications, her long experience – 21 years – in health management and her deep admiration for clinical staff who improve and save people’s lives.

Margie Apa, a Samoan New Zealander, was raised in the low-income suburb of Clover Park, attended Papatoetoe High School and, at the University of Auckland, won a State Services Commission scholarship.

Now, as the founding chief executive of interim Health New Zealand, she is preparing for the operational buck to stop with her for a spend of more than $24 billion a year (although in some ways that responsibility will be shared with the Māori Health Authority).

Ms Apa is based in Auckland at the Health Alliance offices in Penrose, but is initially spending most of her time in Wellington, where she works closely with interim Māori Health Authority chief executive Riana Manuel.

The pair were named in December as the chiefs of the two interim authorities that are to take their permanent shape from 1 July. The 20 DHBs will on that date be collapsed into Health New Zealand, which will run public hospitals and public health units. Health NZ will also commission primary care and hospitals services, and must work with the Māori Health Authority, which has a co-commissioning role.

In the course of a half-hour video interview with New Zealand Doctor that was booked weeks in advance, Ms Apa revealed she is either good at keeping State secrets or good at delegating – meaning there are some things she doesn’t yet need to know.

Take primary care, for example

New Zealand Doctor journalist Fiona Cassie has winkled some details out of the bureaucracy about a capitation funding review that stems from the Waitangi Tribunal’s Wai 2575 claim findings. (See “Capitation funding look-see under way”, 16 March, Print Archive, nzdoctor.co.nz)

Ms Apa adds this: “We’ve been working with the Ministry of Health to give some advice on how we might evolve capitation.”

She says the PHO Services Agreement Amendment Protocol group “initiated a need to review aspects of capitation – probably the main question is whether capitation has kept up with the resource it takes to achieve equity of access”.

Many studies, she says, indicate people living in areas of high deprivation need more care and longer consultations. “The question is, does the capitation formula reflect that adequately.”

When the review might be complete, however, is a question she couldn’t answer – because papers about the review remained unread in her emails. And, when probed on decisions about the size of primary care funding, she simply says, “I don’t know.”

One point she was clear on: the current review will not extend into the Very Low Cost Access scheme – against which many GPs have long campaigned.

The review is “a much more high-level review on whether the formula itself adjusts sufficiently for the cost of providing care to vulnerable people”.

Health NZ is occupying part of the ministry’s Wellington headquarters near Parliament, where about 300 staff have transferred from the ministry, including from the IT, infrastructure, Pacific health and DHB monitoring divisions. Some Health NZ workers are also housed in the central city premises of TAS (Technical Advisory Services). Speaking from TAS’ premises, Ms Apa said developing localities is a key piece of primary care work interim Health NZ has picked up from the Transition Unit.

Asked to describe what localities are, who will own them and how they may be different from locality networks, she says: “I think ‘network’ is probably the key word here, and nobody owns a network.

“What we’ve seen in some places is we have a network of providers who are really focused on developing good access to a range of social and healthcare services for people residing in a place or other jurisdictions. Other systems around the world call them place-based care.

“That’s really the critical factor that they are networks that we resource, support to work collaboratively to listen and hear what the needs of their place or local area is. The job of Health New Zealand is to eventually move to how we can create more flexibility in the funding settings so that those providers aren’t constrained from providing care or joining up care because their contracts don’t work.”

Ms Apa says the health system nationally can learn a lot from the progress of Counties Manukau DHB, where she was chief executive, and from MidCentral DHB, in establishing localities.

She cites the Franklin locality in Counties Manukau as one containing the elements of a “maturing locality”. These include a community advisory group, the DHB as an ordinary provider member, not the leader, a primary care network and marae-based Māori providers.

Asked about her legacy at Counties Manukau DHB, she says she is proud of the clinical leadership team she helped to build, and of a model that allowed clinicians to explain the risks in their services.

“I’m pretty pleased to say that when I inherited Counties as CEO there were some pretty challenging clinical risks which we resourced up – acute care and ED, gynaecology and a number of surgical specialties.

“We were putting funding into our...long-term conditions programme to support vulnerable people with two or more conditions and we were about to launch a locality work programme to take that even further...Nationally those [locality] settings will pick that up.”

She adds to the list the DHB’s central role in caring for people badly burned in the Whakaari White Island eruption, its response to the “pretty difficult” 2019/20 measles epidemic and her senior role in the Auckland region COVID-19 response.

“So I feel pretty proud of what we’ve achieved at Counties despite the [level of] resources that we had.”

When asked about the DHB’s difficulties with obesity and, at times, perinatal mortality, Ms Apa steers the discussion to population determinants of health and how DHBs last year united nationally, hiring dental public health specialist and fizz-fighter Rob Beaglehole to lobby the Government for changes to reduce New Zealanders’ intakes of fat, salt and sugar.

“If we get that [engagement] right, the flow-on effects for equity across other populations, I think, is a really exciting prospect for this role.”

In some ways Ms Apa’s career has run parallel to Transition Unit director Stephen McKernan’s. When asked to name mentors, she pauses momentarily before naming Mr McKernan, followed by Counties Manukau DHB chair Vui Mark Gosche, Auckland University of Technology academic Ella Henry and lawyer Sandra Alofivae.

Mr McKernan was Counties Manukau chief executive for most of Ms Apa’s first stint there, as general manager, Pacific health from 2003 to 2007; and he was director-general at the ministry during much of her tenure there as a deputy director-general from 2007 to 2012.

Several people who have worked near Ms Apa – who all say she is very nice – point to her close working relationship with Mr McKernan. One even suggests a nod from him may have been informally pivotal in her securing the Health NZ chief’s job.

“I work with an amazing group of doctors,” Ms Apa says, “who are very public-service minded and work hard to take their colleagues with them. I have left behind a colleague [acting chief executive and specialist paediatrician] Pete Watson at Counties who has such a heart full for people and service.

“I’m just surrounded, privileged to work with people who really do come to work to do the best.”