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NZ: Health Cheque – book review

Book review:  Gareth Morgan and Geoff Simmons. Health Cheque. The truth about New Zealand’s public health system. PIS, 2009.

Economist Gareth Morgan has some strong views about New Zealand’s health system.  He thinks it’s wrong that the system fails to properly implement simple and cost-effective public health measures for children, such as vaccination, while spending millions on expensive treatments for people who are nearing death.

In Health Cheque, co-authored with Geoff Simmons, Morgan makes a powerful case for making much more effective use of our limited health dollars by concentrating on the early prevention of chronic diseases.  In particular, he says, we need to give far greater attention to preventing obesity.

Morgan has some great credentials for writing about this.  He is rational, positive, fearless, and fair. He praises both former National and Labour governments for some initiatives – National, for example, for introducing Pharmac, and Labour for greatly improving access to primary health care. But both parties also come in for heavy criticism.

Morgan sees John Key’s decision to override the Pharmac decision-making process by backing Herceptin as a dreadful precedent that says to special interest groups that if they make enough noise they will be heard.

He also castigates Labour for introducing the current system of 21 District Health Boards. These, he says, were introduced for political reasons (to remove central government from direct responsibility when things go wrong) and have resulted in huge inefficiencies.  Any meaningful attempt to free up resources by reducing the health bureaucracy, he argues, needs to start with reform of the DHB system.

The book will inevitably attract criticism for being heartless by arguing for reduced medical interventions for those close to death. Such criticism is misguided.

Morgan is calling for a change of emphasis – less medical intervention, but better palliative care. This is where his reasoned, evidence-based approach comes to the fore. A health dollar spent on prevention, particularly for the young, will add much more in terms of QALYs (quality-adjusted life years) than a dollar spent on a coronary bypass for someone in the last years of their life.

Trade-offs like this can’t be avoided, he argues.  Morgan constantly reminds us that we are not rich by first-world standards.  We will not be able to afford to keep up with the ever-increasing costs of new medical treatments and equipment as the number of elderly New Zealanders grows.

Morgan pulls no punches when it comes to obesity prevention, which he sees as becoming a crisis of similar proportions to smoking. He attributes our lack of action to concerns about the ‘nanny state’.  Unless the state intervenes, he says, we will end up instead with the ‘nursery state’ as the effects of unhealthy lifestyles place increasing demands on our health system.  His solutions:

“Getting serious about changing behaviour will mean taxing bad foods or subsidising good food, regulating advertising and labelling, mounting media campaigns with budgets to match McDonald’s and even changing the layout of our cities – currently the car dominates, and walking and cycling are unattractive options” (p.252).

And he doesn’t stop there. In order to afford keeping New Zealanders healthy, he writes, we must look beyond just the health system to such things as improved parenting and warm, dry housing.

Public health advocates will find little new in this book. This is in part because of Morgan’s approach – he has interviewed and listening to the experts, then made his own judgments.  The books’s value lies in making the case for public health measures to combat chronic diseases accessible to a wider audience. Gareth Morgan is hard to ignore.

John White, November 2009

Published on November 28, 2009 in New Zealand news