health & science

NZ’s dirty public health secret out of the bag

The Covid-19 crisis has shone a light on a public health system that has endured year upon year of underfunding, under-resourcing and undervaluing, writes Association of Salaried Medical Specialists' executive director Sarah Dalton

The lack of capacity in New Zealand’s public health units has been comprehensively outed by Dr Ayesha Verrall, in a report which will come as no surprise to those working in the public health space.

In trying to assess whether we can achieve “gold standard” contact tracing, she has pointed out that “the capacity of the country’s 12 public health units is the primary factor in limiting our ability to scale up our case management and tracking response”.

According to the New Zealand College of Public Health Medicine, spending on public health brings improvements in health, wellbeing, and quality of life, and is associated with increased labour supply and productivity, and contributes to economic growth.

It cites a systematic review from 2017 which assessed return on investment of public health interventions in high-income countries with universal healthcare, including New Zealand. It indicated that local and national public health interventions contribute to long-term health gain, with a median return on investment of 14:1 for health spending.

New Zealand has been harbouring a dirty little secret – a public health system which has endured year upon year of underfunding, under-resourcing and undervaluing.

We already live with several less visible epidemics and outbreaks here in Aotearoa: whooping cough, mumps, measles, and believe it or not syphilis. How did we become a country where congenital syphilis is no longer consigned to the annals of medical history and why don’t we seem to care?

Recently a group of public health experts from Otago University’s Department of Public Health lamented the scale of the measles epidemic, linking it to what they saw as the long-term erosion and fragmentation of national public health capacity. They argued for a strong national agency, Public Health Aotearoa, to consolidate public health activities and take responsibility for the growing public health challenges New Zealand faces.

I’ve been speaking to some of our public health specialists who say while Covid cases are now falling, the scrutiny and expectations on the public health workforce are difficult against that backdrop of chronic under-resourcing.

To be fair, the Government has responded and has pumped millions of more dollars in to boost contact tracing capacity, but sadly I think we all know that if Covid-19 had not come along, public health funding would still be flying well under the radar and out of the priority spotlight.

There is of course another issue and that is one of actual workforce capacity and trained staff.

This crisis highlights the need for serious work and thought to go into measuring the appropriate size and distribution of our stretched public health workforce, along with some serious succession planning.

Currently a number of public health units and DHBs do not provide guaranteed training posts for public health registrars, while many public health specialists end up in universities rather than directly in the health system.

At the risk of proposing a silver lining to this Covid pandemic cloud, I’m hopeful that among the many challenges it poses, as a nation we’ll be reminded of the critical importance of our public health function and the specialists and staff who drive it. 

These quiet achievers are often overlooked when we visualise health care. Their work is critical but not glamorous.  No one makes TV dramas about the lives they save, but right now they are the frontline we are relying on.

Maybe now the public’s nascent understanding of concepts like self-isolation, contact tracing, hand hygiene, and infection prevention and control, will stick. 

Maybe, when we’re all allowed out and about again, we can have some more informed conversations about the real value of investing in a robust local and centralised public health function.  

Maybe there will be a shift in health budget management along with a good hard look at capacity, acute demand and staffing.  

Maybe we can look carefully at preventive public health measures as well as planned investment and expansion of our capacity.

And maybe we can remember that our health spend is a valuable investment in our collective wellbeing.

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