To integrate or deintegrate? Fitting public health into New Zealand's reforming health system

The relationship between public health and clinical medicine has been the subject of international debate. In New Zealand successive restructurings of the health sector have seen significant changes in this relationship and the status of public health. The paper traces these changes over a decade of public sector restructuring (1984-1993) and shows how public health policy and the purchasing and delivery of public health services have been subject to integration, deintegration and reintegration with clinical and treatment services. Some advantages flowed from integrating policy, purchasing and delivery, including a comprehensive approach to tackling problems through national health goals and targets. On the other hand, there is evidence that public health was financially disadvantaged by this association. A separate public health structure, set up in 1992 and led by an independent Public Health Commission, brought some benefits. These included a specific budget and a high profile for public health. It also created tensions between competing policy agencies, a fragmented purchasing system for public health and exposed public health to political interference. This led to the abolition of the Commission in 1995 and the reintegration of policy making at the national level and purchasing at the regional level. At the end of 1996 a new coalition government formally abandoned the commercial elements of its predecessor's health reforms. The new policy requires the main providers of hospital and related services, which continue to include public health, to focus on health gains for their defined populations. With the integration of policy and purchasing this should lead to the promotion of better integration at the service delivery revel.