Population Health Congress 2022 speech

Public Health - Lessons from New Zealand’s COVID-19 response and opportunities for the future

E nga mana,

E nga reo,                                         

E nga iwi.

Tēna koutou katoa.

Ka huri ki nga mana whenua o te rohe nei.

Tēna koutou.

He mihi hoki ki a tatou kua tau mai nei I raro I te kaupapa o te rā.

No reira tēna koutou katoa.

Introduction

It is an absolute pleasure to address the Population Health Congress today.

I would like to acknowledge Co-chairs of the Congress, Dr Carmen Parter and Dr Dallas English, and Adjunct Professor Terry Slevin, the CEO of the Public Association of Australia, for your important work and hosting this valuable event. I am sorry that I can’t join you in person.

The invitation I received for this event stated that this Congress is more important than ever, and I fully endorse that statement.

The pandemic justified wide scale action. Not since the influenza pandemic of 1918 had an infectious disease endangered so many.  Our decisions needed to be taken quickly as we saw COVID-19 rapidly spread across the globe.

COVID-19 thrust public health into the limelight. It improved the public’s and media’s literacy with health concepts, and created an entirely new set of experts – the armchair epidemiologists.

The pandemic drew attention to the poor state of public health systems and provided a justification for increased investment.

Covid laid bare inequities in our communities. Communities traditionally underserved by our systems were, and continue to be, disproportionality affected by COVID-19.  Basic public health measures, such as case isolation, shone a light on the inability of many to stay home from work where they would lose income, and as with many infectious diseases, the impacts of poor and overcrowded housing compounded the risk for many, with ethnic inequities particularly stark.  

Now, as we transition out of the emergency phase of the pandemic we must ensure that we use the lessons we learned to inform successful public health action in the future.

In Aotearoa, our recovery from COVID coincides with major reform of our health system.

Through the reforms we have an opportunity to reimagine how we achieve population health.

Today I want to share six lessons I’ve taken from New Zealand’s COVID-19 response and how they can be applied in our new health system to achieve better population health.

The importance and limits of science based decision making

Science was central to our COVID-19 response.

Clearly having a critical mass of technical expertise in government is fundamental, and our Director-General of Health built that up over the pandemic. We also developed processes to capture insights from domestic experts, international posts, scientific literature and modelling.

A variety of external experts from Universities, crown research institutes and clinicians contributed to technical advisory groups.

We established good processes for the incorporation of modelling data into policy advice, enabling us to make decisions about future actions to take, and measures to implement.

Public health decisions held such significance that I established a process for direct independent advice to ministers from external experts on a strategic public health advisory committee.

And even as we transition away from the emergency phase of the covid response we continue to invest in research – we recently announced the results of our third grant round for covid projects.

Evidence is an essential component of public health policy, it enables policy decisions to be more than merely arbitrating between competing interests. 

However the pandemic has also illustrated the challenge of evidence based decision making. No matter how good our evidence base is, the decisions are never completely clear cut and politicians are left with the task of balancing likely risks and outcomes for a range of unknowable future scenarios.

It’s been amusing to see my colleagues become as wary of transmission models as I am (even though the media report the results as forecasts) and as circumspect of laboratory studies to predict the transmission characteristics of new variants.  

Nonetheless we aim to strengthen the contribution of science to our ongoing health decision making through the establishment of an Evidence, Research and Innovation in the Ministry of Health.

We also seek to improve our ability to absorb the benefits of scientific innovation in our health system.

Reform of our therapeutic products legislation will create a regulatory environment where advances in diagnostic tests can be better disseminated. And work to strengthen clinical trials infrastructure offers the opportunity to capture spill over benefits in everyday practice.

Data to drive outcomes

Covid led to the rapid establishment of data infrastructure to support aspects of the pandemic response.

For example, rudimentary contact tracing IT systems run by each of the 12 public health units were replaced with a single national system that enabled contact management, digital sharing of contact tracing work across the country, and high quality reporting.

Data was also integrated between laboratory and notifiable disease information systems.

And the COVID-19 pandemic led to high quality public facing apps for QR-code based location tracking and contact tracing, self administered RAT test reporting, and vaccine passes. 

The pandemic also provided an opportunity for us to establish new systems which we can utilise in the future to monitor and fight public health threats.

We’re already expanding these systems to respond to other infectious diseases. For example the National Contact Tracing Solution has already been updated to enable contact tracing for measles and monkeypox.

The covid immunisation register, a whole population register, has been expanded to incorporate influenza vaccination, and will eventually replace our aging national immunisation register, enabling better information sharing and targeted invitations for vaccination against a variety of diseases.

By highlighting what is possible, the work due to COVID-19 has also spurred activity to develop high quality data systems in other public health settings, especially to ensure underserved populations don’t fall through the cracks, and to enable quality assurance. That’s why I’ve also prioritised major IT developments in women’s health screening as a start.

In New Zealand 271,000 eligible women are not on the breast screening register. And predictably in that group are many traditionally underserved by the health system including many Māori and Pacific women.

We are upgrading the New Zealand Breast Cancer Screening Register so we can ensure women don’t fall through the cracks, with this much better information allowing the careful targeting of bespoke campaigns.

By moving from an “opt in” to an “opt out” register we will improve the reach of breast screening.

Similarly we need to shift from cytological to HPV PCR screening for cervical cancer, and information technology upgrades are an important enabler of this change. A new system will track a woman through the appropriate clinical pathway and generate an alert when a swab or appointment is missed.

More broadly new data systems are seen as a key enabler of the health reforms.

Ultimately we will create a data ecosystem to allow clinicians and consumers to see information from multiple sources in a single view. Providers will also be able to see and correct data about their patients, no matter where across the system that information was generated.

The programme, called HIRA, will also enable greater access to data, particularly primary care data for researchers and decision makers. There is great potential to improve how we pursue population health objectives if we can better connect expertise in epidemiology and data science with community and health sector perspectives.

Strengthen public health systems and institutions.

As I mentioned earlier, we are currently initiating health reforms that are significantly changing our approach to health in New Zealand.

The most important shift is reorienting the whole system towards achieving pae ora - healthy futures for all, so all people, their whānau and communities are supported to achieve their health and wellbeing aspirations.

Overall, this signals reorientation of the whole system towards population health, and a greater focus on prevention of disease, harm and injury.

This is the biggest change in the health system in a generation, and the difficulty and complexity of this challenge cannot be under-estimated. Alignment of every lever will be required to build a sustainable system capable of delivering health gain and health equity.

Our health system now has a stronger focus on public health, with the establishment of a new Public Health Agency within the Ministry of Health, which is responsible for public health policy, strategy and intelligence. It helps us better understand and respond to threats to public health and puts scientific expertise at the heart of policy making.

Te Whatu Ora (Health New Zealand) includes a national public health service, bringing together our Public Health Units under a national banner. This means we’ll be better able to coordinate public health services, responding to threats like COVID-19, measles outbreaks, and smoking.

And Te Aka Whai Ora, our Māori Health Authority, has a central role to lead and monitor change in the way the entire health system understands and responds to the health and wellbeing needs of whānau Māori.

Of course, transformational change won’t happen overnight, and it will take time for some of the deeper issues such as resourcing and inequities to start to improve, but from where I sit, the future of health in New Zealand is very exciting.

The new Public Health Agency is responsible for leading population and public health, in partnership with the Te Aka Whai Ora (Māori Health Authority) and the National Public Health Service.

In particular, the Public Health Agency will lead population and public health strategy, policy, regulatory, technical specifications for public health programmes, intelligence, surveillance and monitoring functions across the health system.

The Public Health Agency will develop a public health strategy and policy framework, which will contribute to the New Zealand Health Plan.

This will incorporate a long-term view, recognising that to achieve pae ora and equity we need to focus on the environments we live, work and play in; the important factors that often sit outside the health system; and challenges and opportunities that are often inter-generational.

The Public Health Agency will also develop a more effective and fit-for-purpose knowledge and surveillance system, supporting a stronger focus on ensuring intelligence directly informs decisions.

This system will draw on both the technical expertise of people in universities and local, community experience and knowledge.

The system will bring together a broad range of data – that is, scientific public health data, as well as insights from engagement with communities and, over time, matauranga Māori.

This joined-up approach offers the best opportunity to help all New Zealanders live longer, healthier lives.

Work across government to address social determinants of health

COVID-19 also taught us how to mobilise all of government around a single objective.

Overnight institutional silos had to be broken down so that health policy could be put into place.

To establish our Managed Isolation & Quarantine System, collaboration was required across a wide range of Government agencies.

To we created a Border Executive Board with representation from Customs, Transport, Foreign Affairs, Immigration and Health to enable a connected approach to managing our health border.

A further example of our collaborative approach was to work with Education and Corrections to both develop and then implement community infection prevention and control guidance in our schools and prisons. This is part prevented a large scale outbreak in these highly vulnerable environments.

We need to continue this type of collaboration, borne out of necessity during the pandemic, to tackle the wider social determinants of health.

The framework to enable this work is already in place. The government budget setting process explicitly focuses on wellbeing objectives.

We’ve also enabled the sort of cross agency collaboration required to tackle complex, multigenerational social problems. For example the joint venture to prevent domestic violence – Te Puna Aonui - brings together ten Government agencies and a workforce of more than 20,000 people to provide whole-of-government strategy, policy, and budgeting advice to Ministers on eliminating family violence and sexual violence, along with analysis and evidence to support decisions and provide oversight of a range of interventions and outcomes across the sector.

The Government is well advanced on ambitious programmes to address the determinants of health

• We are building more houses than any government since the 1970s
• We have taken practical action to address energy security for seniors through the winter energy payment.
• We are overhauling our transport system to achieve mode shift and encourage walking and cycling.
• Reforming water services to give them the financial capability to invest in infrastructure that will give us clean drinking water and keep sewage out of our beaches.

Working across government is clearly essential to address the social determinants of health which has proved a challenge to our health system in the past. In the reformed system the complex task of managing our large health system is delegated to new crown agency, enabling our Ministry of health and public health agency to focus on policy and regulatory work including this cross agency work. These reforms offer a once in a generation opportunity to truly focus on equitable population health and wellbeing.  Through clear separation of strategy and policy, from commissioning and delivery, and monitoring and stewardship at a national level, we will be able to build a system that delivers for all New Zealanders.

Unlock the power of communities

The need to work hand in hand with communities, using their local knowledge and expertise, has been highlighted by the pandemic.

We saw this in our vaccine roll out. We had to work carefully with communities to overcome barriers to access, and to build up trust in a vaccine that has been subject to misinformation.

Successful campaigns have focused on “trusted faces and familiar spaces”.

The spirit of these initiatives was best captured by Super Saturday. During this event, the call out to community leaders, minor celebrities, MPs and an earnest eight-hour live TV broadcast inspired more than 2.5 percent of the population to get vaccinated on one single day. We unleashed the power of our aunties, principals, rugby coaches and pastors to protect our people.

Māori and Pacific health providers were the stars of the vaccine roll out. They reached out to whānau who we have traditionally underserved, by door-knocking, going to workplaces, places of worship, sports and recreation grounds to vaccinate people.

We have learnt lessons along the way. We’ve had to make regulatory changes to enable Maori and Pacific providers to build non-traditional workforces. For example, we have built a workforce of Kaiawhina in Maori health providers for the vaccine roll out. This workforce doesn’t have traditional clinical qualifications but was micro-credentialed for vaccination.

They have successfully and safely vaccinated hundreds of thousands of people traditionally poorly served by the health system. We’re eager to ensure their talents are retained in order to pursue our aspirations for improved childhood immunization coverage and non-communicable disease prevention.

We also learnt how to commission health services in a more flexible and trusting way. This includes improved sharing of health data with community providers.

Community providers integrated measures for their communities. As health services they supported diagnostics, vaccination and linkage to primary care, and they also provided essential social services and food to those in isolation.

Through the health reforms we will continue to utilise the power of community organisations to improve the health of their people. We seek to do this through planning and commissioning primary and community health services in localities.

This ensures health services are tailored to the needs of local populations, because we know that what is needed and works in Te Tai Tokerau, won’t always be exactly what is needed or works in Southland. 

The locality approach brings together local health providers, as well as mana whenua, social agencies and local government, to form provider networks that offer communities more seamless, connected care closer to home.

It emphasises a population health approach, providing for greater partnership with communities, integrated health, and social care for those with complex needs, and building relationships to focus on the broader determinants of health.

Essentially, we’re building a system that puts whānau and communities at the centre and is committed to pae ora for all. It provides for an approach supported by partnership and cross-agency collaboration because we can’t improve people’s health unless we improve their lives.

This presents an exciting opportunity for population health action in the spirt of the Ottawa Charter– localities will provide a structure to strengthen community action, and reorient services locally, to address a range of broader health and related issues such as food environments and activity promoting urban design. Continuing to support community providers will ensure a trusted health workforce is available to address new challenges in non-communicable disease prevention.

Mobilise around an ambitious goal.

Finally, covid-19 has shown us what can be achieved when a country mobilises around an ambitious goal.

The elimination strategy New Zealand adopted in 2020 was ambitious – it offered massive health and economic benefits as long as we could keep covid-19 out of the country. That required us taking a path few other countries took, and implementing stringent measures at our borders and, at times, in our community.

It required unprecedented reorganisation of government, but it also required every citizen to play their part.

The role of our Prime Minister in leading New Zealand through the successful elimination of covid-19 can’t be understated.

Her clear leadership ensured that every level of government knew to reorganise itself around this priority.

Her clear presentation to the public ensured everyone knew what they needed to do, and the trusted partnership established early with the Director-General of Health gave confidence in the response

While the covid-19 is a unique public health emergency we must continue to set ambitious goals and mobilise our communities around a positive vision of their future.  COVID-19 has shown us what is possible when we work together and it is beholden on all of us to learn from, and build on, those lessons.

I’ve found setting ambitious goals to be an important way of communicating government’s ongoing commitment to addressing health threats that matter to people. And in the complexity of a health system undergoing complex reform, clear goals ensures our sector stays focused on outcomes that matter to people. 

That’s why I’ve championed New Zealand’s goal to be Smokefree by 2025.

With 9% of adults being daily smokers, we aim to push the rate to fewer than 5%, and eliminate ethnic inequalities while doing it.

The goal is feasible but it will require bold action.

To achieve this the Smokefree Environments and Regulated Products (Smoked Tobacco) Amendment Bill will make three main changes to tobacco availability and constitution.

Firstly, we will significantly reduce retail availability of smoked tobacco products.

Secondly, we will reduce the nicotine levels of cigarettes so they begin to lose their appeal and addictiveness

And thirdly, we will implement the Smokefree Generation Policy, which will prevent young people, and successive generations, from ever taking up smoking.  This means that no one under the age of 14 when the Bill is passed will ever be able to legally buy a cigarette in New Zealand

I’ve been heartened by the community response to the government’s commitment. I’ve visited Maori health providers who feel that they are getting Government backing to help their communities not only stop smoking, but never start. I’ve also heard from Pacifica organisations that are taking heart from the proposed changes and running smoke free events to de-normalise smoking in their communities

Along with smoking, we’ve also set goals to eliminate HIV transmission and Hepatitis C in Aotearoa New Zealand.

Although New Zealand has not had the severity of impact from HIV and Hepatitis C that other countries have, we have deep inequities in the burden of disease and a real opportunity to eliminate them through bold action.

Setting elimination goals provides the impetus for all players in our health system to work together - whether that be treatment, prevention, drug purchasing or diagnostics.

As an infectious diseases physician I’m also aware of the signal prioritising action on these issues sends to marginalised communities.  They see that we see them, and they matter.

New Zealand is pursuing these ambitious strategies in tobacco and communicable disease control because they are feasible and advance the wellbeing of our people.

Just as we are always interested in learning from others, we hope that as we are successful in achieving our goals, others may look to learn from us in turn.

Closing

To finish, I would like to again thank you for your continued efforts and dedication to supporting the health and wellbeing of your communities, wherever they are.

We should be proud of what our pandemic response has achieved to date, and as we transition to a new approach to COVID-19 you can be confident our determination to protect people is as strong as ever.

I am committed to taking forward our lesson’s learned from this horrific pandemic. Putting strong support behind community action, emphasis on the role of science, collaborative agency work and the critical role of data gathering and sharing.

It is so important that we continue to reflect, learn, and adapt, not only in the pandemic response but as we reform the health system. We have a lot of work to do, but there are many opportunities and I feel optimistic about our future.

Ngā mihi nui kia koutou katoa.