The competing interests shaping health promotion in

New Zealand

Building Community Capacity or Eroding Professional

Capacity?

Sarah Lovellsarah.lovell@otago.ac.nz Ph: +64 3 479 8087Department of Preventive & Social MedicineUniversity of Otago 

The foundations of Health Promotion

The Ottawa Charter for Health Promotion, signed in 1986, identified the role of health promotion being to:Build healthy public policyStrengthen community

actionsCreate supportive

environmentsDevelop personal skillsReorient health service

The politics of health promotion:Self care vs. fostering healthy

environments

Community Capacity Building

Conceptual connections to social capitalCommunity capacity building strategies help to

sustain health promotion programmes beyond their funded life (Hawe, 1998)

Community capacity building is central to the work of health promoters in new Zealand

Community capacity building seeks to enhance the resources, skills, and networks of communities to promote health and wellbeing (Labonte and Laverack, 2001).

The changing health agenda

The 1990s saw a growing contract culture in New Zealand’s health system

“The prescriptive contracting environment of the 1990s has been replaced, in many policy areas, by the rhetoric of partnership” (Matheson, Howden-Chapman and Dew, 2005).

Establishment of DHBs and PHOs cemented the importance of community participation into New Zealand’s health system

Research Rational

What challenges do funders and planners of health promotion face in supporting community capacity building?

Reign of biomedicineCommunity capacity building carried out ‘covertly’ in Australia (Hawe, 1998)

Absence of research on health promotion workforce in New Zealand

History of health system restructuringPHOs another facet of health system change

Political vulnerability

Methods

Study built on earlier researchInterviews conducted with twenty-one planners

and funders of health promotion recruited from five regions:Represented were NGOs (4), PHOs (5), DHBs (3) and

public health units (3) and National NGOs (6) The full range of PHU/DHB relationships was capturedHeavy participation of individuals prominent in health

promotion sectorInterviews, lasting between 18 min and 1hr20min,

were audio-recorded and later transcribedNVivo used to facilitate data analysis

Eroding Community Trust

Turnover of health promotion staff hinders community capacity

Limited-term contracts undermine community relationships

Competition for contracts can strangle opportunities for collaboration with other organisations

“…it's really important to make sure that staff are happy and stay in their jobs… having worked in the community myself before, I know it takes at least three years to develop those sorts of relationships so if you have a high turnover you just don't get anything done and then people lose trust in your organisation, if you like, or that position in terms of having a good relationship so it is important to try and have stable staff….” (N1_NGO)

Health Promotion Workforce

Limited training and workforce development opportunities for regional NGOs

Fundraising a drain on time for NGO health promotersPay equity between organisations

“[There are] major inequalities of salaries and then the NGO health promoters go to the DHB to get more money so it's like robbing or poaching staff… we have no way of dealing with that through scholarships or secondments and those sorts of things have been talked about over the years, heaps over the years, capacity within the NGO, perception of what health promotion is - that's a barrier - you know, and a lack of not just capacity for health promoters in NGOs but just generally lack of capacity.” (PC1:DHB)

“In health in New Zealand with the health reforms that came in when it was made available that non-governmental organisations could actually contract for some of the health funding… and so a lot of NGOs, Maori, Iwi trusts got contracts and weren’t well supported with how they implemented them so there’s some history there with some quite bad stories with funding not being utilised properly, funding being provided and we now have stories of immunisation costing $1000 each and that sort of stuff doesn’t help when it comes to trying to advocate for money to go to these NGOs and local groups. That’s one barrier, I think that because they were set up to fail is part of the issue and then everyone says ‘well they haven’t done it properly so why would we give them more money?' And that sort of thing and it’s really hard to turn around.” (PC1:DHB)

Changing Relationships

Conflicting views on effectiveness of health promotion within PHOs has heightened divisions

Emergence of 80 PHOs diluted potency of PHO funding

Shifting provider landscape has threatened many health promotion contracts

Vulnerability of NGOs in times of political change

“I think health promotion in New Zealand is a mess and I don't think it quite knows what it is and, in general, some sectors are getting on with it and doing a reasonable job like the PHO sector is dong a good job. They've had to. They've got health promotion money, they've attracted a whole lot of people from places and on the whole I think they're doing a really good job at evidence-based health promotion.” (N3)

Building the Capacity of Which Community?

“ I was talking about last year kind of the ultimate community development is when you're not acknowledged. When you're not measured, you know, the outcome isn't your flag-waving. The ultimate community development is when you achieve what you achieve and you slip out the side door when everyone is patting themselves on the back about what a great job they've done and you don't get any recognition at all. And that, that to me, that mode and concept of working doesn't fit too flashly with the model and concept of being in the health sector, you know the medical model, where you've been through for fifteen years to be top of your field and good on you but… you slog your guts out and generally you want some personal acknowledgement of that. “ (PB1:PHO:1)

Poor understanding of community development in health sector

Poor public understanding of health promotionGround-level work dominates community

capacity building/health promotion in New Zealand

Health promotion currently politically vulnerable

Significance

Is health promotion a sector in crisis?

The damage of restructuring

Undermines community relationships and

erodes the capacity of organisations

Insecurity within sector

Bio-medical approaches continue to

dominate budgets

Conclusions

Health promotion has been strangled by a lack of leadershipInnovations are taking place outside

of the sectorFailure of PHOs and public health units to

coordinate their services; who should take the strategic role?

A change in government means a change in health strategy: will health promotion go back in time?

Thanks

To the BRCSS network for funding this postdoctoral research and to Robin Kearns who has been my mentor for the project.