Prof Nick Wilson, Prof Richard Edwards, Prof Tony Blakely
The new draft NZ Health Strategy is strong on strengthening the health care system and has some strong population health aspects, at least rhetorically. It includes phrases like a system moving “from treatment to prevention”.
But how does it fare when considering the science around burden of disease and interventions to address the 10 top risk factors for health loss in NZ? Unfortunately not well at all. There are no population health goals and minimal evidence of concrete action to address the major preventable causes of poor health and premature death. In summary, there seems plenty of scope for upgrading the draft Strategy if it is going to enable New Zealanders to “live well, stay well and get well”.
The draft NZ Health Strategy (1) has a strong focus on strengthening the health care system. As such it addresses the “Get well” part of the “Live well, stay well and get well” goal that it espouses for New Zealanders. It also appears to have some strengths from a population health perspective, at least in its use of language and terminology. Phrases like a system moving “from treatment to prevention” are used and the word “prevention” is mentioned 13 times. It also describes an investment approach focused on long-term benefits.
One of its eight principles is “Collaborative health promotion and disease and injury prevention by all sectors”. It also stresses the theme of “value and high performance” with the word “value” appearing 28 times. It even mentions “inequalities” (albeit just once). But here we look at the draft Strategy document from mainly just one perspective – the degree to which it acknowledges the 10 top risk factors for health loss in NZ, sets out population health goals and proposes strategies to reduce their impact (2) (see Table below).
Smoking – the big risk factor
The number one preventable risk factor for health loss in NZ is tobacco smoking (see Table and Figure). It is also a major contributor to health inequalities. Neither is apparent in the draft Health Strategy, which scarcely mentions tobacco. The Government’s world-leading Smokefree 2025 Goal (3) is not mentioned in any form. Nor does the draft Strategy’s “Roadmap of Actions” include any plans on how to achieve the Smokefree Goal (e.g., via higher tobacco taxes (4), restricting outlets (5), revising regulation around alternative sources of nicotine (6), intensifying mass media campaigns (7) etc).
The Government recently committed to developing a comprehensive strategy for achieving the 2025 Smokefree Goal. This too goes unmentioned. These omissions are difficult to understand given the Government’s commitments to Smokefree 2025 and the rhetoric in a Strategy that claims to be moving ‘from treatment to prevention’. From a value-for-money and investment approach perspective this also seems unfortunate – given NZ modelling work suggesting that tobacco control interventions are highly cost-effective and that higher tobacco taxes, for example, would save health dollars (8) and would probably have other substantial economic benefits (9).
The challenge of increasing levels of obesity is at least acknowledged and described. The word “obesity” gets 13 mentions, and the “Roadmap of Actions” states the intention to “implement a package of initiatives to prevent and manage obesity in children and young people up to 18 years of age”. However, once again there is no population health goal for reducing obesity and the proposed actions do not include any substantive plans to tackle the obesogenic environment (e.g., the words “marketing”, “outlets” and “tax” are not mentioned). Even physical activity only gets one mention with the word “exercise”.
Brief mentions are given to the high blood glucose risk factor (in terms of diabetes), and also the word “alcohol”. But there are no population health goals or substantive primary prevention plans outlined for these risk factors. The lack of focus on alcohol is of note given that this is an area where there is ready scope for large health gains – while also saving health system costs (10).
Top 10 risk factors which are not discussed at all include: “high blood pressure”, “high blood cholesterol”, “high sodium intake”, “high saturated fat intake”, and “adverse health care events”. From an investment approach and value-for-money perspective this also seems unfortunate – given the NZ modelling work that suggests that population-level dietary salt interventions would generally produce large health gains while also saving health dollars (11). Similarly, for NZ work on the benefits of taxing high salt foods (12), and sugary drinks (13).
Where to from here?
In summary, from the perspective of population health and prevention, the draft Strategy is highly inadequate. There is plenty of scope for the draft Strategy to be upgraded to be better based on the science of health loss and to set out a coherent set of priority population health goals and actions to achieve them. Given the clear indication of the cost-effectiveness and substantial economic benefits of such measures, including the benefit of constraining rising health care costs (identified as a major long-term funding issue in the challenges section of the draft Strategy), it is puzzling that the draft Strategy is so bereft in these respects. The final version of the Strategy needs to take a more balanced approach in which key causes of health loss are fully acknowledged and addressed by an appropriate range of strategies and actions to ensure that New Zealanders do indeed “live well, stay well and get well”.
Risk factors for the top 10 causes of health loss in NZ (from the NZ Burden of Disease Study (2))
|Risk factor (top 10)||DALYs (disability-adjusted life-years) lost in 2006||Mentioned in the draft “Health Strategy” (word search terms used)|
|Number||% (of all health loss)|
|1) Tobacco use||86,900||9.1%||“smokefree” (n=2), “tobacco” (n=1), “smoking” (n=0), All nil for: “tax”, “outlets”, “campaigns”, “mass media”, “warning labels”, “2025” (the latter is the year for the Smokefree Nation goal”).|
|2) High BMI||75,100||7.9%||“obesity (n=13). All nil for: “overweight”, “BMI”, “diet”, “obesogenic”, “marketing”, “tax”, “outlets”, “campaigns”, “mass media”. (See also “physical inactivity” below).|
|3) High blood pressure||61,000||6.4%||All nil for: “blood pressure”, “hypertension”, “salt”, “sodium”, “unhealthy” (food)|
|4) High blood glucose||43,800||4.6%||“glucose” (n=0); “diabetes” (n=12) – but the latter contexts do not seem to address the obesogenic environment (see above under “high BMI”).|
|5) Physical inactivity||40,000||4.2%||“exercise” (n=1), “inactivity” (n=0). But the obesogenic environment is not considered (see “High BMI” above).|
(net of benefits & harms)
|3.9%||“alcohol” (n=4), “binge” (n=0). All nil for: with regards to: “marketing”, “tax”, “outlets”.|
|7) High blood cholesterol||30,900||3.2%||All nil for: “cholesterol”, “lipid”, “dietary fat”, “fatty acids”, “diet”|
|8) Adverse health care events||30,300||3.2%||All nil for: “adverse”, “adverse events”, “hospital acquired”, “health care events”.|
|9) High sodium intake||16,300||1.7%||All nil for: “sodium”, “salt”|
|10) High saturated fat intake||11,400||1.2%||All nil for: “saturated fat”, “cholesterol”, “lipid”, “dietary fat”, “fatty acids”, “diet”|
- Ministry of Health: Update of the New Zealand Health Strategy: All New Zealanders live well, stay well, get well: Consultation draft. Wellington: Ministry of Health; 2015.
- Ministry of Health: Health loss in New Zealand: A report from the New Zealand Burden of Diseases, Injuries and Risk Factors Study, 2006–2016. Wellington: Ministry of Health; 2013.
- New Zealand Government: Government Response to the Report of the Māori Affairs Committee on its Inquiry into the tobacco industry in Aotearoa and the consequences of tobacco use for Māori (Final Response). Wellington: New Zealand (NZ) Parliament, 2011.
- Cobiac LJ, Ikeda T, Nghiem N, Blakely T, Wilson N: Modelling the implications of regular increases in tobacco taxation in the tobacco endgame. Tob Control 2015, 24(e2):e154-160.
- Pearson AL, van der Deen FS, Wilson N, Cobiac L, Blakely T: Theoretical impacts of a range of major tobacco retail outlet reduction interventions: modelling results in a country with a smoke-free nation goal. Tob Control 2014, 24:e32-e38.
- Wilson N, Edwards R, Hoek J, Thomson G, Blakely T, van der Deen F, Caldwell B, Crane J: Potential new regulatory options for e-cigarettes in New Zealand. N Z Med J 2015, 128(1425):88-96.
- Edwards R, Hoek J, van der Deen F: Smokefree 2025–use of mass media in New Zealand lacks alignment with evidence and needs. Aust N Z J Public Health 2014, 38(4):395-396.
- Blakely T, Cobiac LJ, Cleghorn CL, Pearson AL, van der Deen FS, Kvizhinadze G, Nghiem N, McLeod M, Wilson N: Health, health inequality, and cost impacts of annual increases in tobacco tax: Multistate life table modeling in New Zealand. PLoS Med 2015, 12(7):e1001856.
- Contreary KA, Chattopadhyay SK, Hopkins DP, Chaloupka FJ, Forster JL, Grimshaw V, Holmes CB, Goetzel RZ, Fielding JE, Community Preventive Services Task F: Economic Impact of Tobacco Price Increases Through Taxation: A Community Guide Systematic Review. Am J Prev Med 2015, 49(5):800-808.
- Cobiac L, Vos T, Doran C, Wallace A: Cost-effectiveness of interventions to prevent alcohol-related disease and injury in Australia. Addiction 2009, 104(10):1646-1655.
- Nghiem N, Blakely T, Cobiac LJ, Pearson AL, Wilson N: Health and economic impacts of eight different dietary salt reduction interventions. PLoS One 2015, 10(4):e0123915.
- Ni Mhurchu C, Eyles H, Genc M, Scarborough P, Rayner M, Mizdrak A, Nnoaham K, Blakely T: Effects of health-related food taxes and subsidies on mortality from diet-related disease in New Zealand: An econometric-epidemiologic modelling study. PLoS One 2015, 10(7):e0128477.
- Ni Mhurchu C, Eyles H, Genc M, Blakely T: Twenty percent tax on fizzy drinks could save lives and generate millions in revenue for health programmes in New Zealand. N Z Med J 2014, 127(1389):92-95.