Abstract:
With a governmental review of the health system impending, it is timely to examine whether the universal capitation-based subsidies engendered by the 2001 Primary Health Care Strategy have achieved and maintained their strategic goal of expanding access to general practitioners and reducing inequities. Prior scholarship finds evidence of reduced fees and increased consultation numbers and rates during the roll-out period, but the long-run picture remains unexplored, and there are multiple hitherto unexamined sources of endogeneity to unravel. This thesis addresses these gaps by examining New Zealand Health Survey data between 2002/03 and 2015/16. I examine the distribution of co-payments, utilisation and unmet need due to cost using regression modelling, accounting for endogenous self-reporting errors and selection effects through instrumentation and Heckman modelling, respectively. I propose a novel instrument to account for selection bias in self-reported fees, applicable in contexts where general practitioners play ‘gate-keeping’ roles for tertiary services.
I find that the expanded universal subsidies were associated with improved access for Māori and more preventive visits as intended. However, patients with the greatest health need made far fewer doctors’ visits per annum than before. After providing universal subsidisation, the fees paid by high- and low-income groups also converged, and low-to-middle-income earners made more use of services but high-income earners did not. The higher rates of utilisation for both the whole population and for Māori have not survived in recent years. I discuss a range of possible explanations for these developments, with particular attention paid to the role of both the capitation subsidies and the subsequent Very-Low Cost Access price-capping scheme.
This research contributes evidence to international scholarship on the link between universal healthcare subsidisation and equity of access, with attention to local nuances. It further provides domestic policymakers with an understanding of the contemporary scope and correlates of poor healthcare access ahead of the health system review.
