Quality improvement perspective and healthcare funding decisions.

This paper reflects on the prioritisation of healthcare funding in New Zealand, identifying the benefits and the shortcomings, it examines whether quality improvement, which is receiving increasing attention in New Zealand and internationally, is useful in making funding decisions. We argue that a quality improvement approach has several advantages over existing prioritisation approaches, and we provide examples of how such an approach might be applied. Major reforms in 1992 resulted in a purchaser-provider split with a strong emphasis on contracting and regulated competition. The Core Services Committee, now the National Health Committee, was established to advise the minister of health on the health service's priorities. The committee proposed that prioritisation decisions should be explicit and transparent and based on four principles, which have underpinned much of its subsequent work: effectiveness, efficiency, equity, and acceptability. The failure to improve Maori health was of particular concern. The principles of the Treaty of Waitangi-partnership, participation, and protection--were identified as central to decision making in the publicly funded health sector in the mid- 1980s. Greater participation by Maori in healthcare decision making and the establishment of "by Maori, for Maori" services occurred, but the three Treaty of Waitangi principles were not explicitly considered when funding decisions were made. The committee developed a unified model for quality improvement across the health sector that identifies four distinct but inter-related levels of activity for quality improvement--individual, team, organisation, and system. In addition, the committee proposed five dimensions of quality that are important in understanding, defining, and improving the quality of health care. Cultural competency is essential for high quality health care and it is integrated across each dimension and level of the model.