A top Auckland doctor was warning the government in January that people were at "serious risk" because the city's public health service was at risk of failing, even as Covid-19 was knocking at the door.
Nine months on, public health specialists say there is little sign the one-off boost to fight the coronavirus will turn into a permanent fix to a system that has been degraded nationwide.
Just how tough staff have been doing it for years in the country's dozen public health units (PHU) - those being lauded now for keeping country safe from Covid by leading contact tracing - is starkly shown in documents newly released by the Ministry of Health under the Official Information Act.
Underfunding for a decade had led to "a population with serious unmet needs and a service at increasing risk of failure in the face of a significant public health threat", Auckland's director of public health Dr William Rainger told the Health Ministry in January.
"The current novel coronavirus [Covid-19] situation is another example of a complex high-risk event which disproportionately affects" the Auckland Regional Public Health Service (ARPHS), he said.
This capped two years of pleading by units for help, while the ministry began various initiatives that stalled:
- a 2014 survey badly outdated public health data systems did not result in action;
- a plan for more equitable funding between public health units disappeared;
- an "action plan" in 2017-18 made no change;
- and a tripartite working group, set up just last year, was still trying to work out what public health services should be funded when Covid hit
Instead, core funding has dropped in real terms as the threat to services rose.
Providing services "is getting increasingly harder", the board chair of Nelson District Health Board told the ministry in September 2019.
To keep abreast of inflation, the 12 units should be getting about $100m now - instead core funding is stuck at $67m, virtually the same dollar amount as in 2010.
In May this year, amid the pandemic, the ministry told units that core funding would stay the same as last year.
"This is because, at this time, there is no sustainable funding uplift allocated under Budget 2020," deputy director-general of population health and prevention Deborah Woodley told the units.
They would get an extra $30m to fight Covid, and extra $3.5m emergency funding to address non-Covid work.
The ministry would focus on ensuring the millions going into contact tracing "provides a basis from which to build a more sustainable public health service", Woodley wrote.
Dr Jim Miller is not convinced.
"Will this stick?" asked Miller, medical officer at Toi Te Ora unit at Bay of Plenty District Health Board, and president of the College of Public Health Medicine.
"I'm not sure.
"I'm not seeing strong evidence of any permanent positions.
"My PHU ... we have not had any permanent positions" created this year.
More than 50 specialists wrote to the prime minister and minister of health in May:
"We cannot make up for more than a decade of underfunding with emergency funding," they said.
They asked for a meeting with the ministers; they have not had one.
"That would certainly be helpful," Miller said.
William Rainger told RNZ the Covid funding had reduced the risks of future pandemics. However, his unit remained short of staff.
Approached by RNZ, the ministry did not address the question of what permanent funding PHUs could expect in future, with its statement confined mostly to talking about Covid - and lauding the units.
"The Ministry of Health highly values the contribution that our PHUs make to improving health and wellbeing outcomes for New Zealanders," it said.
Sharp dips and slides
Analysis of official figures shows public health unit funding took a sharp dip in 2011 and 2014 in real terms, and the slide continued under the Labour-led government at about 3 percent a year.
The ministry notes "small increases" under budgets in 2013 and 2015, but the valleys are deeper than the hills.
This, amid the crises of the swine flu epidemic of 2009, measles and typhoid outbreaks in 2019 and 2017, and the deadly water contamination in Havelock North in 2016.
It was a "panic-and-neglect" response typical of public health services worldwide, Miller said.
"Once the issue [is] over with, the gains that have been made in the public health preparedness are often neglected, until the next time," he said.
An example, the 2019 measles outbreak, when 1500 people got sick here, and there were scores of deaths in Samoa linked to New Zealand's outbreak. A review in July this year of the measles response said:
"On all levels, tasks that belonged in the preparedness phase of outbreak control had been neglected."
Public health units are the proverbial ambulance at the top of the cliff, issuing warnings and education to keep people from getting sick, as well as running defence when people do get sick, most notably Covid contact tracing.
But they have struggled more than any of medicine's 16 branches to attract registrars or the funds to cover training.
The College of Public Health - a sector body, not a school - has doubled trainee numbers to 13 this year.
This was a "one-off" due to Covid, Jim Miller said.
They could train twice as many again - more than 20 - except there was not the money to do it, he said.
It was even less clear if district health boards (DHBs) would do more to help out.
"We really don't know how many funded training positions [in DHBs] are going to be available from one year to the next."
Funding tug of war
The documents show warnings to the government began in mid-2017, from the chair of the three Auckland DHBs Lester Levy to Director-General of Health Chai Chuah.
Levy questioned if they could cope with "several large outbreaks occurring concurrently or a single very serious event taking place such as a pandemic?"
"In other words, does ARPHS (and potentially other public health units in New Zealand) have the resilience to respond effectively to a significant shock or change in underlying conditions?"
The answer is provided across two years of correspondence, revealed by the OIA, showing public health units were aware they not only lacked resilience, but that this would get worse.
"This situation is not sustainable and is now beginning to have a negative impact on the delivery of core public health services in this region," Bay of Plenty DHB chief executive Helen Mason told the ministry in mid-2019.
"If there has been no funding increase from the ministry... I will then inform you as to what services ARPHS will stop," Auckland DHB's chief medical officer Margaret Wilsher told Director-General of Health Ashley Bloomfield in late 2018.
Taranaki and Nelson DHBs sounded similar warnings.
The ministry responded that there was the 2017 "action plan", and in 2019, the tripartite working group - but not that there was extra core funding.
Then minister of health David Clark told DHBs to prioritise support for their public health units.
This was in May 2018; however, there was no extra money in the Budget for that - Auckland DHB had told the ministry this a "very high risk decision".
ARPHS has the lowest per capita funding of any public health unit, of under $10 per head of population, though it has repeatedly told the government it has the biggest load.
It has coped in part by not filling jobs, eight of them in 2017-18, up from five unfilled jobs the year before.
In January this year, Dr Rainger stated that: "The historical degradation of funding has created serious risks for ARPHS and the population we serve."
Important services had been eliminated or reduced, and even so his unit was facing a $2.5m deficit.
"Over the last decade [the unit] has engaged with the ministry on what we consider to be progressive erosion of funding levels relative to the increasing complexity and needs of the Auckland population and the funding distributed across other public health units," he told the ministry.
Covid has proved the point, as Des Gorman, who led official health workforce planning for a decade, told Parliament's Epidemic Response Committee in April.
"We went into this pandemic profoundly under-prepared," said Professor Gorman.
He has previously detailed his failed attempts to overhaul a system that was failing to train enough, or the right, doctors, especially not enough public health specialists.
In a statement to RNZ, ARPHS director Dr Rainger said the pandemic demonstrated the "urgent need" for increased capacity, while giving the upside.
"One of the positive impacts of our collective response is the solid working relationships between key organisations across sectors and between health services," he said.
The border closure had cut down risks from some diseases.
"The resources for contact tracing, disease investigation, public health information and intelligence will improve our response to a range of infectious diseases, such as measles and TB," Rainger said.
However, they had long-standing vacancies that needed filling "to reduce ongoing risks from other infectious diseases like TB, from biosecurity breaches and from hazardous substances in our environment, such as from the SkyCity Convention fire".
The focus on Covid had taken attention away from non-communicable diseases, as well as alcohol consumption, tobacco use and obesity.
A diabetes specialist, Professor Jim Mann, said diabetes was being neglected, even though it was a key risk for making Covid worse.
The one-off Covid funding boost not only had to stick, but spread more widely, Prof Mann said.
"It is absolutely pivotal," he said.
"Because if it doesn't continue, the health service will be not only under pressure, which it is at the moment, but it will be crippled.
"Because the burden of noncommunicable disease is every bit as great as the burden of infectious disease.
"We, in the non-communicable disease area, are just as anxious to see independent, well-funded public health as people are in the infectious disease area."
- Government ends automatic annual increases in Public Health Unit (PHU) funding
- August - Havelock North water contamination; four die
- March-April - Typhoid outbreak infects 22 Aucklanders
- June - Typhoid review finds 'shortcomings'
- September 21 - Auckland Public Health "is not on a sustainable funding track" - Auckland DHB to Ministry of Health
- December 18 - "The Ministry is working … on a public health action plan" - ministry to Auckland DHB
- January 30 - "This is a very high risk decision" - Auckland DHB to ministry about no extra funding for 2018/19
- March 6 - Action plan "is still a priority" - ministry to Auckland DHB
- March 19 - "It may lack the resilience necessary to respond to emerging health risks" - internal ministry memo about Auckland PHU
- May 10 - "I expect DHBs to support their public health units" - Minister of Health David Clark to DHBs
- June 11 - Ashley Bloomfield begins five-year term as director-general of health
- August 27 - "Reprioritisation has eroded capacity in key areas" - Auckland PHU to ministry
- December 17 - "If there has been no funding increase … I will inform you what services will stop" - Auckland DHB to ministry
- January-September - Measles epidemic, with 1500 cases; link to Samoa outbreak that kills scores
- February 8 - "There is no additional funding available this year" - ministry to Auckland DHB
- May 22 - "The deficit is not a situation that is tenable" - Auckland PHU to ministry
- June 11 - "This situation is beginning to have a negative impact on delivery of core public health services" - Bay of Plenty DHB to ministry
- June 24 - "Without additional funding, service delivery will be further constrained" - Taranaki DHB to ministry
- July 10 - "A working group has been established to discuss PHU funding" - ministry to Taranaki DHB
- October - Working group has met three times
- January 24 - "Service is at increasing risk of failure" - Auckland PHU to ministry, noting Covid-19 looming
- March-April - $30m from government to PHUs for Covid public health response
- May 27 - "At this time, there is no sustainable funding uplift allocated under Budget 2020" - ministry to MOH to PHUs, freezing their 2020/21 core budgets
- July - "On all levels, tasks that belonged in the preparedness phase of outbreak control had been neglected" - review of 2019 measles epidemic