‘Printer-ink’ government: Painting new policy directions in health

Often, party manifestos mutate considerably after they are fed into the Wellington policy sausage machine

The finalisation of the coalition agreements on 24 November produced Aotearoa New Zealand’s first “printer ink government” – the blue of National mingling with the yellow and magenta of ACT and the black of New Zealand First.

While this multi-coloured ink is drying on the coalition agreements, the initial focus will be on the parts incorporating aspects of the smaller parties’ election manifestos.

The three-way betrothal of parties signals a range of policy directions: old, new and borrowed.

National, as the senior coalition partner holding the minister of health portfolio and the new mental health portfolio, ensures plenty of blue in the mix.

It’s worth remembering that since the first MMP election of 1996, junior coalition partners (with few exceptions) have had little discernible influence over health policy. Will it be any different this time?

Let’s start with the “new”, which primarily concerns access to medicines. The regulatory environment for medicines has drifted incrementally for decades. While Pharmac has done well to drive hard bargains with pharmaceutical companies, it hasn’t been resourced to deliver timely funding decisions. This is an area of health policy where fresh air could be welcome.

Here, the collective implications of Nationals’ proposals to fund 13 new cancer treatments, the updating of Pharmac’s decision-making model, proposals to streamline Medsafe approvals and David Seymour becoming minister for Pharmac will mean that our medicines and pharmaceutical policy settings may be unrecognisable by 2026.

The playing field clearly looks like it will be tilted towards the pharmaceutical industry. There is some irony in that Pharmac’s achievements in saving taxpayer dollars and maximising government purchasing power would have been wholeheartedly celebrated by the National and ACT parties of the 1990s.

NZ First has also engineered the first significant reverse in tobacco control policy for a generation. National’s health platform and the coalition agreements also indicate that the new Government may pressure professional colleges and universities to change student admission schemes and how professional colleges recognise some international medical graduates. That may make for some interesting relationships with training providers.

Top of the list under the “old” category is the jettisoning of Te Aka Whai Ora, disestablishing TAWO as an independent Crown entity. This will likely happen quickly despite the prospect of opposition from across the health sector. It will give a clear electoral signal to all three parties’ constituencies that they have turned the tide on co-governance. Then, the critical question will be how much the new Government wants to repair relationships with Māori within and beyond the health sector.

I would expect recent developments in collaborative commissioning to continue and funding for Māori providers to improve, albeit with new rhetorical packaging.

However, the distinction between tino rangatiratanga arguments and equity-based arguments for improving Māori health will be blurred in policy.

The old is also represented by the promise made by the new minister of health, Shane Reti, to reintroduce health targets. The big question is to what extent National is prepared to mitigate distortions that health targets are known to produce, particularly when applied to waiting times.

The three coalition parties have also agreed to repeal the Therapeutic Products Act 2023 – hardening a relatively new political fault line regarding whether natural health products are treated primarily as medicines or consumer goods.

Political parties also constantly “borrow” from each other. Much of what National has mooted for mental health and addressing workforce shortages resembles Labour’s policy settings. It’s easier for an opposition party to claim this territory on the campaign trail, given the inevitable lag between the previous Government’s efforts in these spaces and tangible changes.

Most of the proposals listed under “helping more Kiwis fight cancer” are incremental adjustments to existing settings – a tweak in the age of eligibility for publicly-funded screening here, a new guideline for ovarian cancer there.

Even the retention of free prescriptions for Gold Card and Community Services Card holders amounts to borrowing half of the change Labour introduced in the 2022 Budget.

National’s approach to combating vaping for under-18s also has much in common with Labour’s recent approaches.

ACT’s support for pharmacist prescribing and NZ First’s support for expanding nurse practitioners and telehealth in rural areas also consolidate recent policy developments.

If we take the long view, however, election campaign manifestos and coalition agreements are, at best, quite limited indicators of subsequent health policy directions. The real work of substantive change can only start once the new Government has access to the resources of the public sector.

And, often, party manifestos mutate considerably after they are fed into the Wellington policy sausage machine. It’s at this step of the cycle of government where half-baked policy ideas are ditched, others encounter unexpected and expected obstacles, and issues with a higher profile in the health sector but a lower profile in electoral politics take centre stage again.

That’s why, in any change of government, the identity of the minister of health is crucial. Since 2000, the two most influential health ministers – Annette King and Tony Ryall – were in the job in the party’s first term in government.

For Dr Reti, the prospect of updating the funding model for primary healthcare could be the easiest way to make an initial impression. However, even significant increases are unlikely to address workforce issues fully.

He can also significantly mould the shape of Te Whatu Ora while it is malleable, particularly regarding how much decision-making authority will be focused at the regional level.

As for any government, the new Government’s record in health will be judged differently by different people according to different values and interests. But this printer-ink government will also be evaluated on its reliability, as there will be little appetite in the electorate or the health sector for replacing empty or faulty ink cartridges too often.

Tim Tenbensel is professor, health systems, in the Faculty of Medical and Health Sciences at the University of Auckland