5.2 Health system preparednes­s Te takatū a te pūnaha hauora

5.2.1 Pre-existing pressures

Despite its strengths, Aotearoa New Zealand’s health and disability system was already facing multiple pressures going into the pandemic. They included:

• The state of healthcare infrastructure. Many facilities were ageing, and a queue of capital investment projects awaited funding.
• Workforce capacity. Shortages existed in many areas of the health workforce for some time before the pandemic. By the start of 2020, staff shortages were affecting wait times and the quality of patient care in some areas, as well as contributing to heavy workloads and staff burnout. As some parts of the health system relied heavily on workers from overseas, maintaining sufficient workforce capacity depended on immigration settings.
• Growing needs associated with an ageing population with increasingly complex health and disability services.
• Fragmentation and a lack of cohesion across and between health system providers, and unwarranted variation in service delivery between regions and social groups.
• Cost pressures were reflected in the growing fiscal deficits recorded by the country’s twenty district health boards.²
• Some population groups and communities experienced persistently worse health outcomes, often exacerbated by poorer access to healthcare services. They included Māori, Pacific peoples, people in lower socio-economic areas, people with disabilities and some rural communities. Although the Crown has te Tiriti obligations to actively protect Māori health, the Waitangi Tribunal found in 2019 that the health and disability system had repeatedly failed to address many of the intergenerational health problems and inequities Māori faced.³ Inequities in service provision were also apparent between regions, due in part to complex governance arrangements.⁴

The demands of responding to a national pandemic would only intensify these pre-existing vulnerabilities and pressures. As the Ministry of Health noted in its evidence to our Inquiry:

“In the event of a pandemic, significant, extraordinary sector wide effort was going to be required.”

In this regard, Aotearoa New Zealand was far from alone. Health systems in most comparable countries were also struggling with similar population and workforce challenges, and events in the first wave of the pandemic showed that few health systems were equipped to cope with such an emergency, regardless of their level of resourcing.

5.2.2 Prior assessment of pandemic preparedness

Prior to the arrival of COVID-19, Aotearoa New Zealand was thought to be reasonably well-prepared for a major public health emergency, compared to other countries.

In a 2019 assessment of global health security led by Johns Hopkins University, New Zealand had ranked 35th^iv out of 195 countries.⁵ The previous year, a World Health Organization (WHO) evaluation of capacity to detect, report and respond to acute public health events and emergencies had assessed New Zealand as being reasonably well prepared.^v In New Zealand’s health system, the WHO assessors saw evidence of ‘a system and culture of continuous, collaborative improvement through learning from exercises and real-world events that has led to continued investment in preparedness’.⁶

Despite this positive rating, the WHO’s assessors had also emphasised that ongoing vigilance and improvements to New Zealand’s public health systems were needed in advance of a major emergency. They pointed to weaknesses in surveillance, noting that some public health units ‘continue to use paper-based forms for data collection and manually enter the results … leading to a high risk of errors’.⁷ They also highlighted a need for stronger cross-agency work on pandemic preparedness, supported by ‘a formal communication plan for stakeholder engagement and management, including sharing resources and joint emergency response exercises’. More generally, they recommended relevant agencies work together ‘to improve the information and intelligence systems that support decision-making in emergencies’.⁸

Some of the WHO’s concerns about information and intelligence capacity were highlighted again by an independent review of New Zealand’s wider health and disability system in 2020.⁹ That review found gaps in several population health intelligence functions,^vi including monitoring and analysing population changes, investigating patterns of disease and health, interpreting and providing information to support health and disability service activities, investigating variations in health outcomes, and helping ensure strategic decisions were evidence-based.