The viewpoint article by McCool and Bullen in this edition of the Journal makes a compelling case for New Zealand’s continued engagement in global health.1 This engagement is not optional—the choice is between striving for policy coherence across different aspects of our health impact on other nations or continuing to segment the health, economic and environmental impacts of our international activities. New Zealand can contribute as well as learn from the experience of other health systems.
In health system performance comparisons across 7 nations in 2010,2 New Zealand ranks 5th, down from 3rd equal with Australia in 2006.3 We spend less than comparable nations; lead in terms of quality, coordinated and patient-centred care; but languish just ahead of the United States in terms of equity. This reinforces the importance of the recent health equity focus in this Journal and the NZMA,4 and the need to keep health equity uppermost in the health sector’s mind. Progressing health equity needs to strongly engage actors outside of the health sector, both nationally and internationally.
With economic recovery less than certain,5 we need to take a closer look at how other nations are achieving good results for less.6 Innovations are occurring in some countries, such as the Thailand Health Assembly7 which would be valuable in the New Zealand context in developing a greater sense of direction for the sector by bringing together various actors and sectors involved in the social production of health, including groups often marginalized in policy making.
New Zealand’s main contribution to global health derives from our farmers rather than our health workers. In a world that is becoming increasingly food insecure, we ‘punch above our weight” in terms of food exports. Our biggest export,8 dairy products, supplies 35% of the international dairy trade, and has possibly our biggest impact on global health. Our next biggest food export is meat products. A challenge for both these industries, and for New Zealand’s international health reputation, is the extent to which they are able to supply much needed protein to the world, and at the same time avoid contributing to the advancing noncommunicable diseases (NCDs)9 such as diabetes that have reached epidemic proportion in the Pacific, and are fast emerging as the major health challenge of the century, particularly for our growing markets in India and China.
In the past, New Zealand’s trade in goods such as mutton flaps and tobacco have contributed to rising levels of NCDs in the Pacific.10 Currently the dairy industry’s largest export is concentrated or sweetened milk and cream. The free trade agreement with China11 has boosted mutton flap sales to $170m in the last year. Both industries are making efforts to decrease fat content of their products, and develop new products that are more conductive to a healthy life. The net health impact of our food exports is unclear, but as a nation we need in future to play closer attention to making a positive contribution to global food supplies, and not exacerbate recipient countries over nutrition problems.
Better policy coherence is required across our externally focused policies. New Zealand’s current aid strategy of pursuing economic development as a core focus,12 has the potential to further exacerbate NCD rates in the Pacific. This is not without consequence for New Zealand—New Zealand’s health system is footing the bill for the consequences of the rising NCD epidemic, in visitors and migrants from the Pacific.10 This lack of policy coherence means that New Zealand’s trade and aid policies are undermining its own health budget.
Having a healthy, fair and stable region is not just good for others, it is in New Zealand’s self-interest—in containing health care costs, and broader objectives such as regional security, environmental sustainability and economic prosperity. The health of New Zealanders faces real threat from a number of more global sources, more powerful and insidious than traditional infectious threats mentioned by McCool and Bullen.
Free trade agreements threaten to undermine PHARMAC13 a key pillar of the New Zealand health sector’s success. Having developed an agency that consistently negotiated lower prices for essential drugs than other nations, it has been singled out for elimination by Big Pharma, despite, or because of, its attractiveness to health systems worldwide. Our leadership in crafting the tobacco end game14 will require strong global partners to withstand the inevitable legal challenges by Big Tobacco, a preamble to which is currently being played out in Australia as it attempts to pass plain packaging legislation.
Engagement in global health mechanisms is crucial for countries (especially small ones like New Zealand) to participate in decisions and negotiations with much larger players, including the private sector, to mitigate the harmful impacts and leverage positive contributions to health both for New Zealanders and others in our interconnected world.
New Zealand is inextricably linked to the rest of the globalised world, and participates constantly in a range of activities with direct implications for global health, through trade, agriculture, aid, and health policies. The decision on whether to engage is not up for debate—the decision is whether New Zealand engages coherently, explicitly and in a way that optimises the wellbeing of New Zealanders and of those around us.