4th November 2011, Volume 124 Number 1345

Judith McCool, Chris Bullen

In this paper, we examine how, to the contrary, New Zealand has played a key role in influencing global health policy. In a time of fiscal constraint, where it might be tempting to reduce government-level involvement, we argue that small nations such as New Zealand can, and should, continue to exert influence where the opportunities arise.

New Zealand is a signatory to eight international human rights conventions or treaties including the first global health treaty, the World Health Organization (WHO) Framework Convention on Tobacco Control (FCTC). By signing and ratifying these instruments, successive governments have committed New Zealand to making progress to improve the rights and social outcomes, including health, of our people. Indeed, it is the often uncomfortable evidence of the adverse impacts of social and economic inequalities in health within our own populations that has underpinned the New Zealand position on key issues on the global arena.1,2

New Zealand has also played a key role in providing assistance to improve the health of its regional neighbours. This role has never been more relevant or acutely defined since the events of 2009, including the H1N1 pandemic, the economic crisis and global food crisis, and natural disasters.3,4

The current government gives strong priority to economic development and trade, but neither are achievable for any country without good health.5

International context

Globalisation involves the transfer and transgression of goods, services, images and ideas, impacting in diverse ways on health and health equity. As a member of the World Trade Organization, New Zealand has actively pursued globalisation through free trade agreements with larger economies. This has placed pressure on smaller trade partners to accelerate the introduction of trade liberalisation policies. However, such developments can lead to dramatic changes in patterns of work, income, lifestyle behaviours and ultimately in patterns of disease and injury.3

Adverse health impacts are expressed most acutely in settings which are the most poorly resourced to introduce regulatory safeguards. The nations of the Pacific region, for example, face an overwhelming increase in the prevalence of chronic non-communicable diseases (NCDs) such as heart disease, strokes, asthma and diabetes, almost entirely attributable to changes in diet, in tobacco and alcohol consumption and sedentary behaviour associated with urbanisation and globalisation.6

On the other hand, globalisation offers benefits, such as increased access to global export markets, generic pharmaceuticals and other useful goods and services. Indeed, globalisation has resulted in considerable income gains within those countries positioned to take advantage. However, there is also evidence that the economic benefits from globalisation disproportionately favour the already well-off.4The costs of such inequity are yet to be fully accounted for.

Good global health governance is vital to protect people from the risks posed by globalisation. Global health institutions such as the WHO have a mandate to formulate and promulgate health protecting policies to member states. Examples of such policies include the International Health Regulations, which focus on global communicable disease control7 and the FCTC8 discussed earlier.

International health security issues have received greater prominence as public health officials make preparations in anticipation of future pandemic diseases.7 Severe acute respiratory syndrome (SARS) and more recently Influenza A (H1N1) have reinforced the validity of these concerns to human health in New Zealand and the need for New Zealand to be involved in global health policy and action.9

As a member of the WHO Executive Board from 2007–2010, New Zealand was able to advocate on behalf of the nations of the Pacific region to ensure that the issues most critical to the region featured on the global health agenda. In September 2011 New Zealand hosted the Pacific Islands Forum and in the same month, a New Zealand perspective on NCDs was heard at the United Nations Summit in New York. This was an extraordinary opportunity for New Zealand to have a voice on the current status and options for effective global action on NCD.10

Benefits for New Zealand

But what are the benefits for New Zealand to be part of a global health decision-making forum?

First, there is the power of presence: being at the table makes good sense when critical decisions are made that will directly and indirectly impact health through association with allied economies. Active participation at the World Health Assembly means that New Zealand can strengthen and support the Western Pacific Region’s position on a range of critical health issues, particularly those that have direct consequences for the region, for example, climate change. Without presence, there is no voice and no influence on proposed actions.

Second, there are intangible but perhaps more sustainable benefits of global health investment for New Zealand. Since the WHO was established in April 1948 (following earlier initiatives in 1946), there has been a fundamental agreement on the collective benefits of international (cross-border) health security. The focus on international security remains as critical as ever.

For example, the International Health Regulations11 adopted at the 2005 World Health Assembly were the result of a global agreement to upgrade the existing regulations that pre-date the threat of pervasive human health hazards. New Zealand played a critical role in supporting the introduction of the new regulations which were devised as a mechanism for surveillance and control of diseases or organisms which could threaten human health.12 The introduction of international law is logical and sensible in the context of a globalised world which is attempting to achieve goals including the Millennium Development Goals,13 reduce chronic non-communicable disease10 and mitigate the impact of climate change.14

Current and future challenges

Consistent with WHO priorities for the Western Pacific Region, New Zealand’s agenda for global health has been primarily focused on five areas: health systems strengthening, primary care, NCDs, improving aid harmonisation and global governance.15 These areas were prioritised as being of critical importance to a region struggling with persistent preventable communicable disease as well as NCD and a depleted health care system. The outbreak of H1N1 in April 2009 prompted an immediate response from the New Zealand government to contribute to the global and regional response.9 The previous outbreak of SARS was the warm-up for this new virus that threatened to spread swiftly.

However, we argue that a broader perspective on health and a continued interest in the welfare of our neighbours is needed in future. Since 1946, there has been a growing recognition towards recognising that health is not merely the absence of disease (or war), but the well-being within all communities.2Increasingly, health status is understood as a reflection of upstream factors, most of which lie outside the health sector (including trade, politics and workforce issues).16

What, for example, is the role of countries like New Zealand in negotiating workforce development and the push/pull factors which impact on vulnerable Pacific nations? The Pacific region is highly vulnerable to the “pull” of their health workforce to New Zealand and Australia where the income and living conditions are perceived to be an improvement but which has significant capacity issues for the local health services.

New Zealand is noted for “punching above its weight” on the global health stage, for example, through its acknowledged leadership on tobacco control.17 New Zealand has a reputation for constructive participation, negotiation and skilful diplomacy at WHO and UN meetings. We support New Zealand governments in continuing to do this. It is neither practical nor ethical to view health as merely a concern within countries’ own national borders. Acceptance of the responsibilities that accompany being in a globally connected world is a mark of New Zealand’s willingness to play its part, as a relatively well-resourced leader in our region.

Lee Jong-Wook, Director-General of the WHO from2003–2006, stated “a world torn apart by gross health inequalities is in serious trouble ...the global health community can do much to reduce the suffering and death among vulnerable groups”.18 In 2008, the UK Government released a bold strategy, ‘Health is Global’. That strategy set out to: “first, do no harm” through evaluating the impact of global trade agreements on global health and promoting outcomes that support the Millennium Development Goals.

Aside from worthy motives based on concerns for social justice and moral responsibility, the UK government clearly saw a number of benefits arising from its stance, including international trade, security and global alliances and the fundamental protection of health within the UK by “tackling the health challenges that begin outside [their] borders”.9

Reducing health disparities, and reducing health care costs and economic degradation associated with health inequities, is one very powerful motivating force behind the rise and rise of global health investment—from both public and private accounts. Health inequities are one of the most significant threats within the Pacific region. As noted there is a rapidly escalating epidemic of chronic NCDs, environmental effects from climate change loom large and new and re-emerging infectious diseases threaten. More broadly, the region’s economic status as a whole relies upon resource-rich nations to boost overall economic productivity which in the small Pacific islands is waning.20 New Zealand and Australia both play a significant role as do China, Taiwan, Japan and Korea.

New Zealand is well positioned to support the Pacific region on these matters, through participation at the global health level. There is also a case based on enlightened self-interest. There are positive externalities for New Zealand if we contribute building healthy global policy in the Pacific and beyond. These extend beyond the impacts on export trade on the Pacific, with the sustainable management of fisheries, the environment and regional security all having direct implications for New Zealand.

Minister of Foreign Affairs and Trade, Hon Murray McCully stated in a speech to the Centre of Strategic and International Studies in May 2011: “Our economic prospects are deeply intertwined with those of the rapidly growing countries of Asia. Yet both our makeup and our geography give us an increasing involvement in and responsibility for the future stability and security of the Pacific. I often refer to the former as our zone of opportunity and the latter as our zone of responsibility”.21 The message is clear New Zealand is committed to the Pacific region.

However, it is the ways this commitment is expressed in terms of scope, policy and practice that is of concern. In our view New Zealand should ensure strategies are not only relevant to the people of the region but should incorporate a health determinants perspective and continue to build on our well-deserved reputation as a good global citizen and regional leader. We should not and cannot afford to do otherwise.

Abstract

Aim

To review PHARMAC’s decision, effective 1 September 2010, to remove the 1-month restriction on funded prescription of hypnotics and anxiolytics.

Method

We consider the evidence for an association between access to these medicines and risk of harm.

Results

Prescription volumes and reported harms have both increased over the last decade in New Zealand; available studies and clinical experience suggest a causal link. Preliminary data collected since PHARMAC’s funding change suggest an exacerbation of the problem.

Conclusion

The decision to relax funding restrictions on hypnosedatives is expected to increase drug-related harms in a sub-population of users. Improved pharmacovigilance could inform policy regarding these agents.

Author Information

Judith McCool, Senior Lecturer, Global Health; Chris Bullen, Director, Clinical Trials Research Unit; School of Population Health, University of Auckland

Correspondence

Dr Judith McCool, Global Health, School of Population Health, University of Auckland, Private Bag 92019, Auckland 1142, New Zealand.

Correspondence Email

j.mccool@auckland.ac.nz

Competing Interests

None.

References

  1. Arnell T, Stamos MJ, Takahashi P, et al. Colonic stents in colorectal obstruction. Am Surg. 1998;64:986-8.
  2. Londono-Schimmer EE, Leong AP, Phillips RK. Life table analysis of stomal complications following colostomy. Dis Colon Rectum. 1994;37:916-920.
  3. Athreya S, Moss J, Urquhart G, et al. Colorectal stenting for colonic obstruction: the indications, complications, effectiveness and outcome – 5-year review. Eur J Radiol. 2006;60(1):91-94.
  4. Frizelle FA, Carne P, Robertson, G. Colonic stents. ANZ J Surg. 2003:73(Suppl. A17–CR23).
  5. Syn WK, Patel M, Ahmed MM. Metallic stents in large bowel obstruction: experience in a District General Hospital. Colorectal Disease. 2004;7:22-26.
  6. Dohmoto M. New method: endoscopic implantation of rectal stent in palliative treatment of malignant stenosis. Endosc Dig. 1991;3:1507-12.
  7. Carter J, Valmedre S, Dalrymple Cet al. Management of large bowel obstruction in advanced ovarian cancer with intraluminal stents. Gynaecol Oncol. 2002;84:176-9.
  8. Camunez F, Echenageusia A, Simo G, et al. Malignant colorectal obstruction treated by means of self expandable metal stents: effectiveness before surgery and in palliation. Radiology. 2000;216:492-7.
  9. Khot UP, Lang AW, Murali K, Parker MC. Systemic review of the efficacy and safety of colorectal stents. Br J Surg. 2002;89:1096-102.
  10. Keymling M. Colorectal stenting. Endoscopy. 2003;35:234-8.
  11. Mainer A, De Gregorio MA, Tejero E, et al. Acute colorectal obstruction: treatment with self expandable metallic stents before scheduled surgery – results of a multicentre study. Radiology 1999;216:492-7.
  12. Choo YW, Do YS, Suh SWet alMalignant colorectal obstruction: treatment with flexible covered stent. Radiol.1998;206:415-21.
  13. Lopera JE, Ferral H, Wholey M, et alTreatment of colonic obstruction with metal stents; indications, technique and complications. Am J Roentgenol. 1997;169:1285-90.
  14. Baron TH, Dean YA, Yates MR, et alExpandable metal stents for the treatment of colonic obstruction: technical outcomes. Gastrointest Endosc. 1998;47:277-85.
  15. De Gregorio MA, Mainar A, Tejero E, et al. Acute colorectal obstruction: stent placement for palliative treatment – results of a multicentre study. Radiology. 1998;209:117-20.
  16. Osman HS, Rashid HI, Sathananthan N, Parker MC. The cost effectiveness of self-expanding metal stents in the management of malignant left-sided large bowel obstruction. Colorectal Dis. 2000;2:233-7.