Good and not so good of New Zealand’s COVID-19 response and Health Management Information System

New Zealand really deserves appreciation for preventing the local/community spread of COVID-19 for a record 102 days. However, the new wave of novel coronavirus has raised questions on the ‘science-driven response’ promoted by Prime Minister Jacinda Arden. In these circumstances, the island country needs to minimize its dependency on 'strict lockdowns' and move towards implementing a robust health management information system.

New Zealand reported its first confirmed case of COVID-19 on February 28. Thereafter, the government decided to implement a four-level strict lockdown measure to control the outbreak of the diseases. The strategy which was popularized as ‘science-driven response’ by Prime Minister Jacinda Arden yielded results and by May 1, the last case was traced and quarantined. 

Thereafter, the island country successfully prevented the local spread of COVID-19 until August 11 while imported cases were quarantined during this period.

This is indeed a success. But, this also gives rise to two basic questions – firstly, was New Zealand implementing something new? and secondly, whether it has set a benchmark of COVID-19 response? Besides these two questions, the analysis is aimed at presenting a critical review of the existing health management information system in New Zealand.

New Zealand's COVID-19 Response in comparison to neighbors 

The COVID-19 response report submitted by New Zealand to the World Health Organization (WHO) credits strict lockdowns lessons from China, particularly 'speed' of contact tracing, behind its success. "The faster you can find the cases, isolate the cases, and track their close contacts, the more successful you’re going to be,” said the report. Broadly, there are two models of combating COVID-19 i.e., the China (Wuhan) Model which is based on strict lockdown measures and the South Korea Model which emphasizes the use of real-time geospatial data and hi-end technological innovations for social distancing, surveillance, contact tracing, testing, and cure. New Zealand's response seems highly inclined towards China (Wuhan) Model.

As of August 21, New Zealand had reported 1,315 COVID-19 cases and 22 deaths. The island country has a population of about 5 million which is less than Washington DC (5.7 million) and almost equal to the total number of cases in the US (5.5 million). Besides population, several other factors like geography, public healthcare, healthcare communication, internet penetration population density, the socio-economic, and political environment also play a crucial role in combating COVID-19. Therefore, it will not be proper to compare it with the US or any other big country merely based on the total number of cases and deaths. However, a comparison could be made with similar countries as follows:

• New Zealand with a population of 5 million and a population density of 15 people per sq. km reported 1,315 cases and 22 deaths. Here death to infection ration is 1:60. It means, out of every 60 infected persons, one died of COVID-19.
• Singapore with a population of 5.7 million and a population density of 8,358 people per sq km (557 times of New Zealand) reported 56,099 cases but only 27 deaths. Here death to infection ratio was 1:2078.
• South Korea with a population of 51.6 million (five times of New Zealand) and population density of 527 people per sq.km (35 times) reported 16,670 cases (12 times) and 309 deaths (14 times) which has death to infection ratio of 1:54. South Korea is the first country that did not implement strict lockdown in its COVID response strategy.

Similarly, one death was reported on every 265 COVID infections in Sri Lanka, 90 in Papua New Guinea, 74 in Malaysia, Cambodia (273 cases but no deaths), and 62 in the Philippines. Besides, Sri Lanka also conducted general elections on August 5. Thus in terms of death to infection ratio, New Zealand lags behind several countries in the Western Pacific Region of WHO. 

Besides, with 272 cases per million population, New Zealand shares stage with Japan, South Korea, Malaysia, Brunei, DRC Congo, Sudan, South Sudan, Somalia, Ethiopia, Cuba, and Uruguay in the bracket of countries with 100-500 cases per million population category. In terms of deaths per million population, New Zealand with 4.56 deaths per-million population is lagging behind China’s 3.27 deaths per-million population, Malaysia (3.86), Fiji (1.12), DRC Congo (2.7) and Angola (2.74).

These data indicate that New Zealand's COVID-19 seems to be a success in terms of the absolute number of infections and deaths, several countries have performed better in comparative analysis.

Lessons from New Zealand's COVID-19 Response

New Zealand’s initiatives to cushion economic impacts of COVID-19 health crises are highly commendable, particularly its wage subsidy schemes to help employers in paying their employees during the stay at home (lockdown) orders and financial assistance for unemployed workers. The most characteristic feature of New Zealand's lockdown is compulsory 'stay at home' for all. Besides, the government also introduced sector-specific and profession-specific wage schemes which played a big role in saving jobs and freed up cash flow. In addition to these decisions, investing hugely in agriculture, environment, biodiversity conversation, and infrastructure to keep the economy rolling also helped to cushion the economic impact of the health crisis.

But the question is can the New Zealand model of COVID-19 response be implemented in other countries? Several cities in the world have more population than New Zealand such as New York, Washington DC, London (8.9 million), Paris (10.5 million) and New Delhi (19.5 million), etc. Here, in these more populated cities and their countries, strict lockdown and wage schemes may not be a financially viable option. Besides, the low income developing countries will also it difficult to adopt. The technology-driven COVID-19 response of South Korea seems a more feasible model for the world to follow up with. 

Those comparing New Zealand’s COVID response with European countries based on infection and death data seem to ignore the geographical advantages of the island nation. New Zealand neither shares territorial boundaries with any nation nor it is a transit hub for international air or marine traffic. The island country is almost an isolated nation which also makes it easy to implement strict lockdown measures.

But in the absence of a credible set of indicators for comparative analysis of COVID-19 Response across economies, the ruling parties often make claims of success which are flayed by their opponents. Therefore, the WHO should own up the responsibility to develop a set of indicators to compare COVID-19 responses of different countries. These criteria should take into account IHR Capacities, Population, Population Density, Health Information System, Infection to Death Ratio, etc.

Furthermore, over time, the voices are becoming louder from within for an Official Inquiry into the COVID-19 Response of the country. The first big dent in this image came from the irresponsible behavior of the Health Minister himself who was forced to resign for breaking rules to take his family to the beach. And the second is the decision of the Prime Minister to postpone the General Election. However, a survey conducted in mid-June claims that the number of people judging New Zealand’s COVID-19 response as ‘excellent’ had come down from 74% to 53% in a week. It indicates all is not well in the island country. The doubts are also being raised on whether New Zealand compromised with the management of other infectious diseases in handling COVID-19 through strict lockdowns.

However, the lockdown strategy of New Zealand which is based on speedy contact-tracing and graded response may still guide nations in improving their COVID-19 response.

WHO’s Assessment of New Zealand’ IHR Capacity Progress  

Though based on voluntary disclosures, WHO provides an assessment of the International Health Regulation (IHR) Capacity Progress of member countries on an annual basis. 

The IHR Capacity Progress 2019 of New Zealand shows degradation in four capacities in comparison to the previous year – Risk Communication, Point of Entry, Health Service Provision, and Food Safety while no improvement was shown in Surveillance, Laboratory, and Zoonotic Events. These capacities are crucial for COVID-19 response. In 2019, New Zealand was given full marks only in three IHR capacities – IHR Coordination and National IHR Focal Points (Coordination with WHO), National Health Emergency Framework, and Chemical Events.

The WHO, however, has not developed any criteria or set of indicators to compare COVID-19 response across countries. 

Healthcare System in New Zealand

Healthcare in New Zealand in primarily public-funded and centrally controlled by the Ministry of Health. Since 1938, New Zealand has developed a consensus that the government has a fundamental role in providing healthcare and nobody should be denied healthcare facilities. The country has a three-tier healthcare system - primary healthcare centers at community/local level, District Health Boards (DHBs), and the Ministry of Health at the national level. 

District Health Boards, one each in 20 districts, play a crucial role in the healthcare system of New Zealand as they are autonomous bodies with responsibilities of planning, purchasing, providing health services at the local level, and also quality control while primary healthcare centers are meant for community-level services. Ministry of Health acts as Central nodal body for planning and execution of healthcare policies also responsible to ensure that various agencies such as the Health Research Council, Pharmaceutical Management Agency (PHARMAC), Health Quality and Safety Commission, Technology and Digital Services Business Unit, Health Workforce New Zealand, NZ Health Partnerships and Health Promotion Agency work in cohesion. The PHARMAC's innovative approach is credited for the 3rd rank for New Zealand in OECD countries in terms of the 'highest proportion of generic medicines by volume'.

There is almost 100% insurance cover in New Zealand, primarily by public insurance. The public and private healthcare insurance companies have their respective list of healthcare services to cover.

However, developmental disparity, discrimination, and the digital divide have been a major problem in the country. The Maori and Pacific communities have the least access to the resources. The government has launched the Maori Innovation Fund, Pacific Innovation Fund, and disease or health event-specific initiatives such as mental health, alcoholism, smoking, aging, and cancer, etc. to address these problems. As per the report, about 98 percent of people of Maori and Pacific communities who are CSC holders are enrolled with a practice that offers lower-cost fees.

As per the data of 2017, health spending constitutes about 9 percent of GDP of which public spending accounted for about 79 percent of total spending. Some of the characteristic features of New Zealand’s healthcare system are as follows:

New Zealand Health Strategy 2016-26

New Zealand Health Strategy 2016 is a ten-years long-term comprehensive health plan for the country which replaced previous health strategy developed in 2000. The Strategy is centered around the vision ‘All New Zealanders live well, stay well, get well’.

It has two components -  Future Direction and Roadmap of Actions. The former outlines the high-level direction for New Zealand’s health system from 2016 to 2026 while the latter comprises 27 areas of implementable actions that are organized under five healthcare themes. They are as follows:

• People Powered: This theme is aimed at making New Zealanders ‘health smart’ which involves communicating well and supporting people’s navigation of the system including the use of accessible technology including mobile phones and the internet. The initiatives under this theme are aimed at enabling people to take greater control of their health by making informed choices and accessing relevant information to make informed decisions.
• Closer to Home: The projects, plans, and initiatives under this theme are aimed at providing healthcare services to the people close to their homes, whānau (extended family), schools, workplaces, and playgrounds, etc. They are mainly community-level initiatives by the government or with the help of NGOs/CSOs.
• Value and High Performance: This theme is related to improving healthcare quality for individual patients, population (across communities), and the system. The implementable actions under this theme are designed to ensure optimum utilization of resources and provide high-quality, affordable, accessible health services to the people besides ensuring New Zealand’s Institute for Healthcare Improvement’s Triple Aim: improved quality, safety, and experience of care; improved health and equity for all populations; and better value for public health system resources.
• One Team: The health strategy is also aimed at integrating person, family, whanau (extended family), and primary healthcare centers. The initiatives under this theme follow community approach which is very helpful in the cases of mental health, aging, psychological diseases, alcoholism, and substance abuse. They include community outreach programs conducted with the help of NGOs/CSOs. 
• Smart System: The theme deals with the technological interventions in the healthcare system including digitization, interoperability, e-Referrals, android mobile data, and the internet of things (IoT), etc. 

Responsibility and Accountability

District Health Boards are primarily accountable for quality control of healthcare services in their respective territorial jurisdictions. This accountability is formally measured on a set of achievable targets across a range of indicators that are cross verified with health surveys through participatory monitoring. These parameters include, but are not limited to, waiting time for patients, access to primary care, and mental health outcomes, etc. Besides, there is a system of performance assessment and performance-based payments for primary health organizations and private medical practitioners too. 

The district health boards have reportedly implemented clinical governance, which means that management and health professionals have assumed joint accountability for quality, patient safety, and financial performance. Besides, the Ministry of Health provides them guidelines for quality improvement from time to time. District level alliances have multiple cross-sector members including primary care, pharmacies, ambulance services, district nursing, allied health, local government, and Maori providers (a dedicated service for indigenous people to address discrimination). District health boards develop services as per the local needs and also partner with local social agencies.

Health literacy

Health literacy is a unique program of New Zealand aimed at improving the understanding of common people about health information. This program facilitates healthcare communication and also the crisis communication for preventive health. Though the communication efforts of Prime Minister Jacinda Arden deserve appreciation, the existence of such a system plays a vital role in health communication at the time of crisis.

Patient Experience Survey

Through legislation in 2014, New Zealand made it mandatory for public hospitals to conduct patient experience surveys through random sampling. The findings of these surveys are published by the Health Quality and Safety Commission. Besides, it has a 24x7 phone-based ‘healthline’ for round-the-clock doctor service for the needy. 

Health and Disability Commissioner

Health and Disability Commissioner acts independently from the government and directly reports to the Parliament. The official acts as ‘health ombudsman’ and national advocate for patients. It investigates patients’ complaints and presents reports to the Parliament.

Healthcare Management Information System in New Zealand

Digitization of healthcare services is still a work in progress in New Zealand. In 2015, the Ministry of Health launched the Digital Health Work Program 2020 to ensure the availability of high-quality health and wellness information facilitated by a single electronic health record. However, the National Health Information Platform is still un unfinished agenda.

The government has reportedly completed the target of universalizing electronic health records but interoperability is still a challenge and faces regional disparity. Presently, the facilities of the interoperability of electronic health records are available in only one of the four regions. Besides, only 509 of 992 general practices have implemented provider portals. Despite this, the county has also witnessed a significant increase in telehealth services in the Northern Region and patients increasingly using electronic health records to get appointments and avail health services.

As per the Annual Report 2019, the patient experience survey conducted through DHBs reveals that the hospitals scored about 8/10 marks. The data was primarily collected through digital mode, online surveys, and android mobiles were also used. However, statistical data collection is also in practice through surveys and presented in the form of reports. The report uses four sources for data collection – Ministry of Health Website, National Health Index, National Immunization Register, and Pharmacy Electronic Claims. It claims to have a strong cybersecurity system as not even a single security breach was reported in 2017-18 and 2018-19.

In May 2019, New Zealand also tested a pilot project ‘No Credit, No Worries’ to improve equity by enabling people to access online health resources without using mobile data. As per the report, about 85% of people had smartphones at the time of the pilot project but not everyone has a credit on their phone.

However, the National Health Information Platform which is aimed at bringing together health information from the health and disability system so it can be accessed by New Zealanders, health care providers, and planners is yet to be materialized.  

Conclusion and Agenda for Discussion

New Zealand's initiatives to cushion the economic impact of the COVID-19 health crisis particularly wage schemes are commendable and lessons from its lockdown may help other countries in improving their pandemic response. However, the island country itself needs to improve on the front of technology in its COVID-19 response. It was with the use of technology in South Korea first organized general election in mid-April. Most recently, Sri Lanka also successfully conducted general elections on August 5 while New Zealand decided to postpone elections. 

The independent reviews of New Zealand’s COVID-19 response also indicate its over-dependency on strict lockdowns and the need for improvement on the use of digital technologies to support contact tracing, testing, and surveillance for early outbreak detection. New Zealand’s 'NZ COVID Tracer App' has reportedly received several complaints. Besides, New Zealand’s COVID response lacks real-time geospatial data-based information technologies for implementing social distancing, AI-based contact tracing, COVID alerts, testing, quarantine, treatment, and supply chains management. Besides, New Zealand also needs a national data policy to use real-time geospatial data for the healthcare management information system.

New Zealand's high ranking among 37 OECD countries in terms of COVID-19 response maybe because most of the members are from Europe, which was hit hard in the early months of COVID-19 pandemic. 

Discrimination is still a major challenge for New Zealand’s health system and subsequently to its health management information system. Besides, the country is also facing increasing problems of aging, dementia, mental health, suicides, and smocking, particularly in indigenous Maori girls.

The experiences of New Zealand affirm that the peace-meal approach against a pandemic like COVID-19 may provide some initial benefits but a robust and holistic health management information system (HMIS) is need of the hour. The Ideal HMIS should rely on real-time geospatial data sourced from various components of the healthcare system and integrated through AI (Artificial Intelligence) based virtual platform. Besides, Ideal HMIS should also have features for infodemic management, patient care, interoperability, and supply chain management. There is a great need to adopt a holistic approach towards healthcare to develop an Ideal HMIS which is resilient to unforeseen pandemics and natural disasters of the future.

VisionRI's Centre of Excellence on Emerging Development Perspectives (COE-EDP) aims to keep track of the transition trajectory of global development and works towards conceptualization, development, and mainstreaming of innovative developmental approaches, frameworks, and practices.