One country, four systems: Comparing changing health policies in New Zealand

There is a growing literature in comparative health policy that analyzes the experiences of different countries. This article draws upon the comparative tradition, but has an intra-country focus. It considers the case of New Zealand, which has had four different public health sector structures in a decade, with fundamental changes enacted following general elections in 1990, 1996 and 1999. New Zealand's structures have included a system of locally based area health boards responsible for both funding and services delivery in their regions; a competitive, profit-oriented market system with separate agencies purchasing and providing health-care services; a centralized system with one corporate agency planning for population needs and purchasing services from a range of providers; and a system in which planning and purchasing is devolved to district boards. In tandem with the constant restructurings, a variety of policy and service innovations have emerged in areas such as the organization of primary-care physicians, indigenous Maori health care, pharmaceutical purchasing and the prioritization of services and patients. First, the article reviews the field of comparative health policy studies. Next, it outlines New Zealand's four health sector structures. Lastly, the article discusses the performance, implications and lessons of New Zealand's successive health sector changes.