On my first full day in New Zealand, I met the founder of 1000Minds, a company that develops decision-making software and tools for prioritization and group decision-making; the chief economist for the ministry of health and her policy team; and the chair and CEO of PHARMAC, the crown jewel of New Zealand’s health care system, the pharmacy management arm that has achieved incredible results in managing costs while pharmacy utilization rises like it does everywhere else. And I realized, there are some major advantages to living in a small place (“New Zealand is a small town”). For instance, you can meet the board chair and the CEO of the crown jewel of the country’s health care system even though you ostensibly represent no value to them whatsoever.
One of the other advantages of being small is that you can get away with stuff. PHARMAC negotiates hard, and achieves phenomenal pricing and terms from pharmaceutical companies. Contrary to what many people think about PHARMAC, they do not get to those results via bulk purchasing and leverage. In fact, they purchase nothing (they serve as agents on behalf of the district health boards, local or regional entities that administer the public health scheme), and they have no scale to speak of. New Zealand, with only four million people, represents just 0.1% of the global pharmaceutical market. So they don’t get what they get because they’re big. Rather, they get what they get because they’re small. It matters a lot less to drug makers what New Zealand pays for drugs than it does in a place like the U.S.
When you’re small, you can also do things like establish a national framework for the patient experience in hospitals across the country. I heard about this initiative, just kicking off, from the Ministry of Health policy analysts. Perhaps because many New Zealanders do not have a choice of providers because of limited supply of doctors and hospitals outside the main urban areas, the way in which hospitals treat patients matters. It’s also a society that espouses fairness, and seems to actually embody an authentic “niceness” As a New Englander, I’m bred to be pretty wary of people who are too nice, and I’ve honed an instinct for people who are faking. My read is that these people are not. At least everyone I met went out of their way to help me and seemed genuinely not to think there was another option. In this environment, you can imagine gathering a robust and representative assortment of experts and constituents, and working with them to set a standard, and then having just about 50 hospitals in the whole country actually adhere to them. Isn’t small beautiful?
The New Zealand health system is not perfect. There can be long waiting lists in the public sector for elective procedures (that probably stop feeling elective over time). There is the ACC (the Accident Compensation Corporation), a public, no-fault personal injury scheme which covers anyone for any accident-related injury and thus creates incentives to throw yourself down the stairs if you have a trick knee to cut the line for elective surgery (I hope no one actually does that, but the incentive is there). There is a theoretically sufficient supply of high-quality doctors, but those doctors aren’t distributed well, and so rural areas suffer capacity shortages. Additionally, New Zealand, like Australia, allows doctors significant latitude to charge whatever fees they like on top of the government reimbursement, so many people grumble about the ever-increasing gap payments they must make to GPs.
There are ethnic disparities here, despite a society deeply rooted in fairness. The native Maori people make up about 15% of the population, and have shorter life expectancy, less access to care, and greater disease burden. Sound familiar? Like every indigenous and minority population? The Maori, though, seem to have a respected place in Kiwi society. They have a treaty with the crown, which brought New Zealand under British rule, and that treaty provides respect and protection for the Maori people. Nearly all signs and postings are displayed in Maori along side English. And many of the places retain their Maori names. Unlike most parts of Australia, you can see people who look plausibly like indigenous people (though many no doubt come from a range of Pacific locales). Not ideal or close to perfect, but it seems that Maori issues and language and culture are threaded throughout the mainstream culture and language. That seems like a road going in the right direction towards greater equity.
New Zealand’s focus on fairness doesn’t result from a perfect or clean history with regards to injustice. Of course there has been (and probably still is) injustice. But they have had the humility and the courage to acknowledge their history and confront it.
Throughout the world New Zealanders are known as neutral and practical. This position gets them seats at much bigger tables on the world stage than they otherwise would. They seem to broker deals and offer positions that many factions can get behind. They seem reasonable after all, and they’re not threatening. We may as well go with what the Kiwis suggest.
My sense is also that Kiwis are doers. They’re organized. They’re competent. They may not bother much with conceptual frameworks, but rather, they’ll just dig in and figure things out. “New Zealanders are very good at making things work on the smell of an oily rag.” And they’re relaxed. When my host one evening learned that I’m allergic to peppers (capsicum here), he tossed aside his plan to cook chili con carne with what seemed like an awfully genuine and almost delighted chuckle. “Not to worry. I hadn’t started yet. I’ll make a Bolognese instead!”
After all, they live here:
I might find an inner peace if I lived here, too.