Healthy Eating – Healthy Action:
Oranga Kai – Oranga Pumau
Strategy Evaluation
Interim Report
HEHA Strategy
Evaluation Consortium
April 2009
1
Acknowledgements
We would like to thank the key informants who willingly gave of their time to
participate in this research, as well as the officials in a range of government agencies
who have responded to our various queries.
We would also like to thank the Evaluation Reference Group who provided valuable
advice during the preparation of this document.
2
HEHA Strategy Evaluation Consortium
University of Otago
The HEHA Strategy Evaluation Consortium is a team of researchers from AUT
University, Native Consultancy Ltd, and Whakauae Research Services Victoria
University of Wellington, and the University of Otago, led by the University of Otago.
Full list of authors:
Steering group:
Professor Jim Mann (Director, University of Otago)
Margaret Johnston (Project Administrator, University of Otago)
Dr Rachael McLean (Project Manager, University of Otago)
Professor Janet Hoek (University of Otago)
Associate Professor Jacqueline Cumming (Victoria University of
Wellington)
Professor Grant Schofield (AUT University)
Other Researchers
Involved in Writing
the Report Include:
Bronwyn Andrews (Victoria University of Wellington)
Dr Amohia Boulton (Whakauae Research Services)
Sue Buckley (Victoria University of Wellington)
Mili Burnette (Victoria University of Wellington)
Marianna Churchward (Victoria University of Wellington)
Dr Bronwyn Croxson (Victoria University of Wellington)
Dr Scott Duncan (AUT University)
Terry Ehau (Native Consultancy Ltd)
Dr Ausaga Fa’asalele Tanuvasa (Victoria University of Wellington)
Sandy Fowler (Victoria University of Wellington)
Dr Heather Gifford (Whakauae Research Services)
Dr Terri Green (University of Canterbury)
Dr Erica Hinckson (AUT University)
Dr Andrea Insch (University of Otago)
Prof Mike Lean (University of Otago)
Dr Janet McDonald (Victoria University of Wellington)
Julia McPhee (AUT University)
Erana Skudder (Victoria University of Wellington)
Dr Louise Signal (University of Otago)
Tua Sua (Victoria University of Wellington)
Dr Rachael Taylor (University of Otago)
Mat Walton (Victoria University of Wellington)
Associate Professor Sheila Williams (University of Otago)
3
Abbreviations
ACC
ANA
DAP
DHB
ECE
FiS
FTEs
GRx
HEHA
HRC
MAPs
MoE
MoH
MSD
NAG
NGO
NHF
NZHS
NZ PAQ
NZPAS
OTA
PA
PHDAP
PHO
PHU
SPARC
TPK
WHO
Accident Compensation Corporation
Agencies for Nutrition Action
District Annual Plan
District Health Board
Early Childhood Education
Fruit in Schools
Full Time Equivalents
Green Prescription
Healthy Eating – Healthy Action
Health Research Council
Ministry Approved Plans
Ministry of Education
Ministry of Health
Ministry of Social Development
National Administration Guideline
Non Governmental Organisation
National Heart Foundation
New Zealand Health Survey
New Zealand Physical Activity Questionnaire
New Zealand Physical Activity Survey
Obstacles to Action
Physical Activity
Pacific Health and Disability Action Plan
Primary Health Organisation
Public Health Unit
Sport and Recreation New Zealand
Te Puni Kōkiri
World Health Organization
4
Table of Contents:
Preface ................................................................................................................................................................ 9
Executive Summary.....................................................................................................................................10
Introduction ...................................................................................................................................................19
Conceptual Framework ....................................................................................................................28
Workstreams ........................................................................................................................................30
Section 1: Implementation ......................................................................................................................32
Summary.....................................................................................................................................................32
Introduction ..............................................................................................................................................34
Research Questions ................................................................................................................................35
Methods.......................................................................................................................................................36
Results .........................................................................................................................................................39
1. Implementation ..............................................................................................................................40
2. Outcomes ..........................................................................................................................................64
3. Improvement/Development of the Strategy.......................................................................70
3. Māori response to the Implementation of the HEHA Strategy .....................................74
4. HEHA Strategy Evaluation: the views of Pacific Policy-makers .............................. 101
Discussion: Implementation HEHA Strategy ............................................................................. 116
Strengths and Limitations................................................................................................................. 118
Recommendations ............................................................................................................................... 118
Section 2: Population Data ................................................................................................................... 120
Summary.................................................................................................................................................. 120
Introduction ........................................................................................................................................... 120
Methods.................................................................................................................................................... 121
Baseline Data Results.......................................................................................................................... 123
Baseline data: 2002/3 New Zealand Health Survey ............................................................... 146
Time trend data ................................................................................................................................. 149
Section 3: Stocktake of HEHA Initiatives ........................................................................................ 154
Summary.................................................................................................................................................. 154
Introduction ........................................................................................................................................... 155
Methods.................................................................................................................................................... 155
Results ...................................................................................................................................................... 158
Section 4: Review of Food Supply and Environmental Interventions ................................. 165
Introduction ........................................................................................................................................... 165
Analysis of the Food Industry Group Database ........................................................................ 166
Section 5: Value for Money ................................................................................................................... 178
Summary.................................................................................................................................................. 178
Introduction ........................................................................................................................................... 179
Research Questions ............................................................................................................................. 180
Methods.................................................................................................................................................... 180
Results ...................................................................................................................................................... 184
Conclusions ............................................................................................................................................. 225
Recommendations .................................................................................................................................... 226
5
List of tables:
Table 1 HEHA Strategy Timeline............................................................................................................23
Table 2: Key Informants ............................................................................................................................38
Table 3: Te Tuhono Oranga Evaluation Framework ......................................................................98
Table 4: Fono Fale model integration in Evaluation ................................................................... 101
Table 5: Nationally representative datasets containing information on nutrition,
physical activity and body size ................................................................................................... 122
Table 6: International cut-off points for adults aged 18 years and over adapted from
WHO 2000(2) .................................................................................................................................... 123
Table 7: Classification of obesity and overweight according to BMI (kg/m2) used in
interpretation of New Zealand data prior to 2006/07 NZHS (53) ............................... 123
Table 8: Prevalence of Obesity Māori Adults using ethnic specific and standard BMI cutpoints in published data ............................................................................................................... 124
Table 9: Nationally representative surveys where height and weight have been
measured ............................................................................................................................................ 124
Table 10: Prevalence (%) of Overweight and Obesity by Ethnicity 2002/03 NZHS....... 128
Table 11: Prevalence (%) of Obesity by Deprivation 2002/03 NZHS .................................. 129
Table 12: Time trends in Physical Activity and Inactivity- Health Surveys ...................... 132
Table 13: Barriers and Motivators for Physical Activity (Source 2003 Obstacles to Action
Survey ) ............................................................................................................................................... 135
Table 14: Barriers and Motivators for Physical Activity by Gender (Source 2003
Obstacles to Action Survey )........................................................................................................ 137
Table 15: Barriers and Motivators for Physical Activity by Age (Source 2003 Obstacles
to Action Survey) ............................................................................................................................. 138
Table 16: Barriers and Motivators for Physical Activity by Ethnicity (Source 2003
Obstacles to Action Survey)......................................................................................................... 139
Table 17: Population surveys nutrition data ................................................................................ 144
Table 18: Number of initiatives by type .......................................................................................... 159
Table 19: Number of initiatives by target population group: priority groups .................. 160
Table 20: Number of initiatives by target population group: children, youth and adults
................................................................................................................................................................ 161
Table 21: Number of initiatives by outcome (Ottawa Charter) ............................................. 161
Table 22: Number of initiatives by outcome (Other) .................................................................. 162
Table 23: Number of initiatives by target outcome ..................................................................... 163
Table 24: Number of initiative by setting: School ........................................................................ 163
Table 25: Number of initiative by setting: community .............................................................. 164
Table 26: Identification of Nutrition, Marketing or Advertising Policies ............................ 167
Table 27: Changes to Food Formulation .......................................................................................... 170
Table 28: Education Measures Implemented ................................................................................ 173
Table 29 HEHA related funding 2006/07 ($ million per annum, GST exclusive) ............ 188
Table 30:HEHA-related funding 2007/08 ($ million per annum, GST exclusive) ........... 188
Table 31:Ministry of Health HEHA budget allocation 2006-2011 as at 2006 ($ millions
GST exclusive) ................................................................................................................................... 191
Table 32 Summary of HEHA work programme funding 2007/08 ($ millions GST
exclusive) ............................................................................................................................................ 193
Table 33 Summary of HEHA work programme funding 2008/09 (GST exclusive) ........ 194
Table 34 Mission-On Funding ($ milions GST exclusive) .......................................................... 198
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Table 35 Contribution to Mission-On from Vote Health including HEHA budget
allocation ($ millions GST exclusive) ....................................................................................... 199
Table 36 Estimated cost of Mission-On initiatives ($ millions GST exclusive) ................. 199
Table 37 Green prescription RST and PHO funding (GST exclusive) .................................... 201
Table 38 Stocktake funding by funder (1994 – 2012)................................................................ 205
Table 39 Total HEHA funding 2005 – 2010 ($ million GST exclusive)................................. 213
Table 40 FTEs employed to implement and coordinate HEHA............................................... 216
Table of figures:
Figure 1 Nutrition and Physical Activity Infrastructure Under HEHA ....................................12
Figure 2 HEHA Strategy Overarching Intervention Logic(9) ......................................................20
Figure 3 Relationship between HEHA and Mission On projects (Source Ministry of
Health HEHA team personal communication) ........................................................................22
Figure 4 Nutrition and Physical Activity Infrastructure 2003 ...................................................26
Figure 5 Nutrition and Physical Activity Infrastructure Under HEHA ....................................27
Figure 6 Prevalence of Obesity (Female, age adjusted %) by Deprivation 2002/03 NZHS
................................................................................................................................................................ 125
Figure 7 Prevalence of Obesity (Male, age adjusted %) by Deprivation 2002/03 NZHS
................................................................................................................................................................ 126
Figure 8 Prevalence of Obesity (age adjusted %) by Ethnicity 2002/3 NZHS .................. 127
Figure 9 Prevalence of Overweight (age adjusted %) by Ethnicity 2002/3 NZHS .......... 128
Figure 10 Prevalence of adult (15+ years of age) obesity 1977 - 2006-07(54, p4) ........ 130
Figure 11: Shift in population BMI distribution, ages 20 - 64, 1977 - 2007(54) .............. 131
Figure 12: Regular physical activity for adults, by age group and gender (unadjusted
prevalence) (Source 2006/07 New Zealand Health Survey) ......................................... 133
Figure 13: Regular physical activity for adults, by ethnic group and gender (age
standardised rate ratio) ................................................................................................................ 134
Figure 14: Mean PA Barrier Percent by Gender (Source 2003 Obstacles to Action
Survey)................................................................................................................................................. 138
Figure 15: Mean PA Barrier Percent by Age (Source 2003 Obstacles to Action Survey)
................................................................................................................................................................ 139
Figure 16: Mean PA Barrier Percent by Age (Source 2003 Obstacles to Action Survey)
................................................................................................................................................................ 141
Figure 17: Availability of Environmental Motivators for PA (Source 2003 Obstacles to
ActionSurvey) ................................................................................................................................... 142
Figure 18: Perceived environmental barriers to PA (Source 2003 Obstacles to Action
Survey)................................................................................................................................................. 143
Figure 19: Vegetable intake (three or more servings per day) in adults, by ethnic group
and sex (age standardised) Source: 2002/03 NZHS (53) ............................................... 146
Figure 20: Vegetable intake (three or more servings per day) in adults, by NZDep2001
quintile and sex (age-standardised). Source 2002/03 NZHS (53) ............................... 147
Figure 21: Vegetable intake (three or more servings per day) in adults, by age group and
sex. Source 2002/03 NZHS (53) ............................................................................................... 147
Figure 22: Fruit intake (two or more servings per day) in adults, by ethnic group and
sex (age standardised). Source 2002/3 NZHS(53)............................................................. 148
Figure 23: Fruit intake (two or more servings per day) in adults, by NZDep2001 quintile
and sex (age standardised). Source 2002/03 NZHS(53) ................................................. 148
7
Figure 24: Fruit intake (two or more servings per day) in adults, by age group and sex.
Source 2002/3 NZHS (53) ........................................................................................................... 149
Figure 25: Adequate vegetable intake for adults, by gender, 1997, 2002/03 and
2006/07 (age standardised prevalence) (2) ........................................................................ 150
Figure 26: Adequate vegetable intake for Māori adults, by gender, 1997, 2002/3,
2006/7 (age standardised prevalence) (9) ........................................................................... 151
Figure 27: Adequate fruit intake for adults, by gender, 1997, 2002/03 and 2006/07 (age
standardised prevalence) (2) ..................................................................................................... 152
Figure 28: Ministry of Health HEHA budget allocation breakdown by activity area 20062011 (GST exclusive) ..................................................................................................................... 191
Figure 29 Ministry of Health HEHA programme funding as per 2007/08 Business Plan
($ millions GST exclusive) ............................................................................................................ 196
Figure 30 Ministry of Health HEHA programme funding as per 2008/09 Business Plan ($
millions GST exclusive) ..................................................................................................................... 197
Figure 31 Stocktake $ by programme type (excluding 7 large council funded initiatives)
1994 -2012 ......................................................................................................................................... 203
Figure 32 Number of programmes by funding amount ............................................................. 204
Figure 33 Stocktake total HEHA funding by main activity year blocks ............................... 205
Figure 34 Stocktake total HEHA funding by DHB region (excluding nationwide and
multiple region programme funding) ..................................................................................... 206
Figure 35 Stocktake total HEHA funding by DHB region per head of DHB population . 207
Figure 36 Stocktake total HEHA funding by identified programme outcome ................... 208
Figure 37 Stocktake total HEHA funding by identified programme setting ............................. 209
Figure 38 Stocktake total HEHA funding by identified programme target population ........ 210
Figure 39 Stocktake total HEHA funding by identified programme target outcome ..... 211
Figure 40 Stocktake total HEHA funding by identified programme environment outcome
................................................................................................................................................................ 212
Figure 41 Total HEHA funding 2005/06 – 2009/10 by funding agency ............................. 214
Figure 42 Total HEHA funding 2005/06 to 2009/10 ................................................................. 214
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Preface
This is the first interim report for the evaluation of the Healthy Eating – Healthy Action:
Oranga Kai – Oranga Pumau (HEHA) Strategy. This evaluation was to be undertaken by
the Consortium over a three-year period to 2011, in line with the Evaluation Methods
Plan submitted to the Ministry of Health in 2008. This interim report contains
preliminary findings only. The HEHA Strategy has three goals: improving nutrition,
increasing physical activity and reducing obesity. These are longterm goals and will be
evaluated in subsequent Evaluation reports.
The purpose of this interim report is to provide initial and preliminary findings
regarding implementation, and lay the ground for subsequent analysis of outcomes with
respect to environmental and behaviour change, and prevalence of overweight and
obesity. This can be done as further data is available for the HEHA stocktake, and data
from the Nutrition and Physical Activity Survey becomes available. In addition, a
further full analysis of value for money will be undertaken. An ongoing focus on
improvement will be a feature of these reports as the strategy progresses. In particular
the following subsequent reports were planned:




November 2009: First Full Value for Money Analysis
November 2010: Second Interim Draft Evaluation Report
August 2011 Full Evaluation Draft Report
November 2011 Final Evaluation Report
9
Executive Summary
The Healthy Eating - Healthy Action: Oranga Kai - Oranga Pumau (HEHA) Strategy was
launched by the Ministry of Health in 2003 in response to increasing New Zealand
concern about an increasing prevalence of obesity, and the associated increased risk of
chronic diseases, notably diabetes, cardiovascular disease and cancer. A detailed
implementation plan, and evaluation informed by research that examines the process of
implementation, strategy outcomes, and value for money, contribute to the unique
nature of HEHA. The Strategy uses the World Health Organization’s Ottawa Charter for
Health Promotion to focus approaches for action, and has a reducing inequalities focus,
which is consistent with international best practice for health promotion.
This is the first interim report for the HEHA Strategy evaluation. It contains early and
preliminary findings, which reflect both the short time period of the evaluation, as well
as the relatively early period of the Strategy implementation. The original intention of
the evaluation was that it would be undertaken by the Consortium over a three-year
period to 2011, in line with the Evaluation Methods Plan submitted to the Ministry of
Health in 2008. In particular the following subsequent reports were planned:




December 2009: First Full Value for Money Analysis (subsequently incorporated
into the Value for Money section of the revised First Interim Evaluation Report)
November 2010: Second Interim Draft Evaluation Report
August 2011 Full Evaluation Draft Report
November 2011 Final Evaluation Report
The full evaluation was to have included:
 Full VFM analysis
 Extension stocktake to end 2010
 Another round of interviews in 2010
 Examination of effect of supply and environmental initiatives
 Outcomes data analysis with respect to the HEHA goals of improving nutrition,
increasing physical activity and reducing obesity.
Clearly policy changes during 2009 regarding obesity related strategies have
profoundly influenced this Evaluation. However, we believe that this First Interim
Evaluation Report as well as the final Evaluation Report at the end of the contract will
provide helpful information.
The Strategy has been developed in the context of increasing obesity prevalence, and
evidence of poor nutrition and inadequate levels of physical activity in New Zealand.
New Zealand rates of obesity and overweight have increased since the 1980s,
particularly in Māori and Pacific people and those living in deprived areas. (1). The
2006/7 New Zealand Health Survey reported that 29% of NZ children aged 2-14 years
and 63% of NZ adults were classified as overweight or obese. Time trend data show that
10
increases in obesity prevalence may have slowed from 2002/03 to 2006/07; (2)
however, further data points are required to establish whether this is the beginning of a
new trend. For this report, baseline data are considered to be generally that of 2002/03
as this predates the HEHA Strategy development and implementation, although the
majority of initiatives were funded from 2007 (see below: value for money).
Behaviours contributing to the obesity epidemic also require monitoring and analysis.
While physical activity levels have remained relatively stable in New Zealand over the
past decade, only about half of New Zealanders regularly exercise for 30 minutes per
session, at least five times a week. Furthermore, only two-thirds of adults report eating
the recommended three or more servings of vegetables per day, while just over half
reported eating the recommended two or more servings of fruit each day.(2)
These statistics underpin the key HEHA goals of increasing physical activity and
improving nutrition, which are vital to reducing obesity and associated co-morbidities.
Assessing progress in attaining these goals requires further analysis of existing data sets
from national surveys, and collection of new data, from the Nutrition and Physical
Activity Survey, which has been designed to monitor environmental and behavioral
changes. Such analyses, together with evaluation of the strategy, its implementation,
longer term outcomes and value for money, had been intended to form the basis of
subsequent reports and, where identified, opportunities for improvement.
Stocktake of HEHA initiatives
A comprehensive stock-take of all national, regional, and local HEHA and HEHA-related
initiatives up to March 2009 has captured data on more than 1200 initiatives, and has
been provided to the Ministry as a separate database. Preliminary analyses suggest
these effectively reach Māori and Pacific peoples, though coverage for Asian and South
Asian groups is low. There is a preponderance of local initiatives, complemented by
several strong national programmes. Physical activity programmes outnumber
nutrition programmes, largely because physical activity initiatives are made available
by many different parties (e.g., city and regional councils, sporting organisations). More
emphasis needs to be placed on assessing which opportunities work and for whom, and
how uptake of these could be enhanced.
Information from the Food Industry Group (FIG) database reveals the food industry has
emphasised product development, in line with the FIG’s mission, but there is insufficient
information to assess how these initiatives have affected consumers’ overall food
supply, or the HEHA objective of improving nutrition. While most initiatives were
designed to reduce consumption of high fat, salt and sugar products, only a small
number aimed to increase fruit or vegetable consumption. Detailed case studies are
required; these would require access to companies’ sales data, which should be used to
examine progress towards specific targets. Such a process is critical to assessing the
contribution FIG members’ initiatives have made to HEHA objectives.
11
Implementation
This report includes assessment of the implementation of the HEHA Strategy up to the
end of April, 2009. Data for this part of the evaluation was collected through interviews
and focus groups with a total of 105 key informants (from the Ministry of Health, other
government agencies, DHB and Public Health Unit personnel in HEHA-related roles,
national NGOs and Māori and Pacific policymakers) and from an analysis of key
documents.
Interview topics included leadership of HEHA, the development of collaborative
relationships, engagement with priority groups addressed by the Strategy, DHBs’ HEHA
planning processes, implementation activities, outcomes of the Strategy to date, and
suggestions for improvement. The semi-structured interviews were transcribed and
analysed thematically in relation to the key interview questions as well as identifying
additional issues raised.
A complex infrastructure was put in place to support the HEHA Strategy (see Figure 1).
The Ministry of Health was generally recognised by key informants to be leading the
Strategy effectively, however, some DHB participants considered the Ministry of Health
is sometimes too prescriptive about implementation and could communicate better
about impending changes. DHBs viewed themselves as the local implementers of the
Strategy, but the need for this layer was questioned by some NGO key informants. Some
NGO key informants were also concerned about the role and influence of the food
industry in the implementation of the HEHA Strategy.
Figure 1 Nutrition and Physical Activity Infrastructure Under HEHA
Ministry of Health
Advisory Groups
New Zealand
Health Strategy
2000
External Coordination
Group 2004-2006
Interagency
Steering
Group 2007
Sector Steering Group
2008
HEHA Strategy 2003
HEHA Implementation Plan 2004
Ministerial Advisory
Group 2008
Sport and
Recreation New
Zealand (SPARC)
Māori and Pacific
Caucuses
Public
Health
Operations
Office of the
Director of
Public
Health
Expanded
HEHA Project
Team
Central
Government
Agencies
Nutrition and
Physical
Activity
Policy
Mission-On
2006-09
District Health
Boards (21)
Public Health
Units (12)
HEHA project
manager & district
coordinator
HEHA Ministry
Approved Plan
Fruit in Schools
NonGovernmental
Organisations
(NGOs)
District HEHA Action Groups
and HEHA initiatives, including:
DHBs, PHOs, local and central
govt, NGOs,
(Ministry of Health, SPARC,
Ministry of Education, Ministry
Youth Development)
Health
Sponsorship
Council
Feeding our
Futures campaign
Regional
Sports Trusts
Directly funded
initiatives e.g.
breastfeeding,
FBCS support
Physical activity
programmes
12
All key informants agreed on the importance of collaboration for the success of the
Strategy yet did not always find this easy in practice, but recognised that it needs time
and trust to develop. The Ministry of Health itself was seen to need better co-ordination
across all the Directorates that have a role in HEHA. Good collaboration seemed to have
developed between the Ministry of Health, the Ministry of Education and Sport and
Recreation New Zealand (SPARC), in part due to the mandate from their Ministers to
work together on Mission-On initiatives (also including the Ministry of Youth
Development), and because of an earlier formal Tripartite Memorandum of
Understanding, which has now ceased. Inter-governmental collaboration on HEHA
beyond these agencies seemed less well developed at this stage, with a need to build
stronger linkages around shared issues.
DHBs were developing collaborative relationships with local stakeholders, including the
formation of intersectoral steering groups as required by the Ministry of Health. Overall,
collaboration seemed to be easier for smaller DHBs with pre-existing working
relationships with their community partners, and for DHBs with a stronger pre-existing
population health focus. Good collaboration between agencies at a national level was
also reported to help facilitate local relationships. Where DHBs were able to contribute
some funding to stakeholders, this also helped in building partnerships. Some
informants questioned the need for the new DHB project manager role. Collaboration
was more difficult for Public Health Units which cover more than one DHB area (with
the different DHBs sometimes having varying priorities and approaches).
Engagement with the priority groups identified by the Strategy – Māori, Pacific, children
and families, and lower socio-economic groups – was a focus for the Ministry of Health
and DHBs, although not all other government agencies focus their work on these
particular groups. Effectiveness of partnerships between DHBs and Māori and Pacific
peoples seemed to be variable. The need for community level engagement was
emphasised by the requirement that DHBs engage with these groups and include them
in governance. The focus on children and families was largely being actioned through
work in the education sector. Engagement with lower socioeconomic groups seemed to
be less direct than with the other priority groups, being expressed mainly through work
in low decile schools and in some overlap with Māori and Pacific work.
DHBs have used their usual planning processes and appeared to have consulted widely
to develop HEHA plans for their districts. However developing the required Ministry
Approved Plans (MAPs) was perceived to be complex and time consuming. Many DHB
key informants would prefer on-going integration of HEHA into the general District
Annual Plan and this will occur going forward, as the Ministry of Health will not require
DHBs to develop a third MAP. The Ministry of Health reported close alignment of
implementation with the Implementation Plan, although DHBs and other sectors
seemed to be working more directly from their own planning documents. On-going
workforce capacity building was recognised by many to be needed to support HEHA
implementation.
Key informants considered all six of the Strategy’s approaches for action are a necessary
part of HEHA’s multi-faceted approach. However, there was most support, across key
13
informants, for ‘working to ensure healthy policy’ and ‘creating supportive
environments’ to make behaviour change easy, and the Stocktake confirms these are the
two strongest foci of HEHA initiatives.
A wide variety of means were being used to encourage the continual sharing of new
learning about HEHA among stakeholders, including a bimonthly newsletter, e-mail
updates, the on-line HEHA Network and Knowledge Library, and the HEHA evaluation
Toolbox.
Key informants identified two main outcomes of HEHA to date. The first was increased
awareness in society of the problem of obesity and the need for good nutrition and
exercise. The second was changes in the school and pre-school environment. There was
little specific evidence to quantify changes to date. Key informants believed outcomes
from HEHA may be difficult to measure, need time to eventuate, and may be hard to
attribute specifically to HEHA. Creating supportive environments in schools, leadership
and collaboration were identified by key informants as factors contributing to
successful change.
The Strategy may be improved by continuing to build engagement and collaboration,
with the Ministry of Health building stronger links with NGOs, some government
agencies, and with local government. NGO key informants would like to see more action
on environmental change, while DHB key informants sought certainty about the future
direction and funding of HEHA and would like more flexibility in how they can
implement the Strategy.
Views of Māori policymakers
Māori policy makers and key informants largely agreed that the HEHA Strategy has had
some success in changing people’s views and attitudes towards healthy eating and
physical activity and has gone some way to providing a solid foundation for future public
health efforts to reduce obesity amongst the Māori population. Māori key informants
commented that the HEHA ’brand’ is certainly well-known and well recognised in the Māori
community and Māori whānau and communities are much more aware of the need to eat
healthily and maintain a certain level of physical activity. Importantly, the interviews
indicate that these messages are also being picked up by children.
Participants reported short-term process and impact outcomes such as increased
collaboration, greater community engagement, evidence of uptake of HEHA initiatives
and increased social cohesion as resulting from the Strategy. Some evaluations of local
HEHA projects sought to measure what participants were valuing as culturally specific
outcomes and these may have been different from outcomes expected by the funder.
For instance, a sense of greater whānaungatanga was valued as an outcome by
participants, but may be challenged as a satisfactory measure of obesity reduction by
the funder. Some success had been measured anecdotally through individual success
stories and attendance at hui by participants, indicating support for the Strategy.
14
The HEHA strategy appeared to be well targeted to Māori communities and Māori
communities have been supportive of the Strategy. However, this support has not been
without reservations. The key concerns were that the Strategy was a top down imposition on
Māori communities; that it often relied on local level leadership within DHBs to advance the
Strategy resulting in variability in the success of the implementation; and subsequent
withdrawal of components of the Strategy had adversely impacted on providers and
communities who had already done considerable groundwork in preparing
communities for interventions and had set up programmes only to find them severely
curtailed or withdrawn.
Improved monitoring of how DHBs spent their allocation of HEHA funding, greater
involvement by Māori communities earlier on and, in some cases, greater autonomy and
control over funding decisions affecting Māori communities, would have made a difference
to how the community perceived and engaged with the HEHA Strategy. In the areas where
Māori participation in the HEHA programme was high, this was attributed to committed and
knowledgeable Māori health professionals, who knew, understood and were able to
articulate the public health and health promotion goals inherent in the HEHA Strategy.
Key informants identified that an increase in access to services and resulting changes in
Māori environments may impact in the longer term on reducing inequalities. However
as some HEHA initiatives are cross-sectoral, the ability to influence outcomes from
within the health sector is challenging. Changes to the wider national HEHA
programme, resulting in the cessation of, or changes to, some programmes, means we
may never be able to measure longer term outcomes arising from the Strategy .
Participants commented that evaluation results were starting to be reported when policy
changes were made. While outcome measurement and building an evidence base is
challenging there has been some capacity building within Māori providers as part of HEHA
initiatives. This may result in providers being better able to identify programme logic and
determine short, medium and long-term outcomes, and acquire skills and knowledge to carry
out the necessary evaluation to determine effectiveness of HEHA initiatives.
Greater structural and environmental change to support the gains made to date and
how the messages and lessons learned will be sustained into the future appear were
two key concerns raised by respondents in deciding whether overall the HEHA Strategy
has been a success.
Views of Pacific Policymakers
Pacific policymakers reported a lack of consultation in the early stages of the Strategy
development, although this has subsequently improved, particularly with the
appointment of a HEHA Target Champion and through engagement around Community
Action projects. Pacific policymakers consider Pacific leadership at all levels of HEHA is
important.
Pacific policymakers and key informants felt workforce development was important to
enable Pacific communities to determine their own needs and empower them to take
action (as has happened with the Community Action projects), rather than telling them
what to do. Moreover, sustainability of this workforce was also considered important
15
through encouraging those who undertake nutrition classes to consider long-term
career goals beyond initial training.
Key informants considered that the initial implementation of HEHA had resulted in
several positive outcomes for Pacific people, including more people exercising and
healthier food being served at some community gatherings, although they considered
that there was less change at large community celebrations and serving portions might
still be too big. Key informants have suggested that awareness within Pacific
communities about HEHA issues has grown, and there is community support for
change. However, evidence to measure Pacific outcomes or changes in inequality is seen
to be lacking, and monitoring of this is needed.
Value for Money
One of the key questions for the evaluation is: has the HEHA Strategy and its
implementation resulted in value-for-money? This first report focuses on identifying
the national level funding provided for HEHA, the range of initiatives allocated money at
DHB level, early views of key informants on whether the Strategy and its
implementation are likely to result in value-for-money, and an indication of the best mix
of initiatives to maximise outcomes.
From an analysis of budget documents and stocktake data, we have identified high-level
funding for HEHA-related activities at around $328 million between 2005 and 2010,
although this is likely to be an under-estimate given the large number of initiatives
where no budget information was available.
Initiatives stocktake data collected for this evaluation was recorded at the individual
programme level. Funding data for 437 of the 1256 recorded programmes shows that
funding was predominantly allocated to nutrition and physical activity programmes in
community and educational settings, with a child and family/whānau population group
focus.
Government budget documents data shows proposed funding allocations by area of
activity (e.g. leadership, breastfeeding, primary care), which differ from the outcome
areas identified for stocktake initiative. This makes detailed comparisons between the
two funding data sources extremely difficult, however school and community focussed
workstreams were also consistently amongst the highest funded workstreams in the
annual budget allocations.
In general, key informants believed that the Strategy would deliver value for money, but
that it would be some time before clear measurable impacts would be seen.
In general, HEHA was seen as prescriptive, and DHB key informants expressed a desire
for more local flexibility in determining their own spending priorities and more
consultation with the Ministry of Health over funding decisions and priorities. Some
DHB informants were also concerned over resource allocation particularly with regard
to the project manager and district co-ordinator positions, where there was one of each
for every DHB, regardless of its population size.
16
Funding for HEHA was generally considered to be adequate or at least matched to
existing capacity, although some NGOs would like more funding. A number of DHBs
have contributed their own additional funding to HEHA-type work while others
reported having no access to other funding beyond that allocated by the Ministry of
Health. Many key informants felt that there was little or “no security whatsoever” in
relation to HEHA funding, and were concerned over the potential damage that
withdrawing funding from community projects could have on working relationships
and future initiatives.
Limited information could be gathered on the mix of initiatives likely to maximise
achievement of HEHA Strategy goals, due to several methodological limitations.
However, some indications of the programmes most valued by key informants were
gained. Valued programmes included: the Nutrition Fund and education District
Coordinators; the enhanced Green Prescription programme; the Community Action
Fund to address health needs within Māori and Pacific communities; breastfeeding
initiatives; and leadership and coordination of HEHA programmes at DHB level.
Resources may be able to be redirected towards the highly valued programmes
through: small marginal cuts across the range of programmes, particularly
communications; improving targeting of programmes to community health needs; and
reducing duplication between programmes.
Summary
In summary, analyses of population data sets confirm the need for a national strategy
designed to reduce obesity. The HEHA Strategy implementation is generally well
regarded, although questions regarding flexibility and better recognition of regional
diversity require further exploration. Food industry initiatives have focussed on
product development; however, more specific data are required to assess whether these
have improved overall nutrition. The evaluation will be of international as well as
national importance since no other country has attempted to evaluate a comprehensive
strategy aimed at reducing the risk of chronic diseases.
Limitations
There are substantial methodological challenges of measuring a complex multidimensional program such as this, and this is reflected in the original time frame for the
evaluation up to 2011. Although the HEHA Strategy was launched in 2003, given its
goals we expect that it will take many years for interventions to show measurable
changes in physical activity and nutrition outcomes. The following limitations are
highlighted:
 The implementation section of this report focuses on interviews with national
policy makers and key staff in DHBs. No interviews have been completed at a
community level; these will take place in early 2010 to give a fuller picture of the
implementation of HEHA.
17


Data for analysis of outcomes from the Nutrition and Physical Activity Survey
and other sources is not yet available. This report therefore contains only an
outline of some baseline data, which will be used in subsequent analysis.
Due to delays in finalising the Supply and Environmental part of the Evaluation
Methods Plan, this section contains very preliminary findings only.
Key Recommendations:
1. The HEHA Strategy should continue to be implemented nationally with its
current framework, which includes the goals of improving nurtrition, increasing
physical activity and reducing obesity. The current focus on priority population
groups of lower socioeconomic groups, children, young people, families/ whānau
should also continue. At this stage we believe that the risks of any substantial
change in direction of the strategy will outweigh any perceived benefits. .
2. The Strategy should maintain an emphasis on environmental change to facilitate
changes in behaviour. Those who implement HEHA should continue to look for
opportunities to create environmental change to support healthy eating and
physical activity.
3. Focus should be maintained on the importance of nutrition to reduce obesity,
and the current imbalance towards physical activity indicated by the Stocktake
should be addressed.
4. Consideration should be given to allowing the District Health Boards more
flexibility to develop priorities at a local level within an appropriate
accountability framework.
5. Consideration should be given to ensuring the ongoing security of future
Strategy funding, which is key to the continuation of established initiatives, and
maintaining institutional expertise and a culture of improvement.
6. HEHA funding that is specifically targeted for Māori and Pacific people should be
audited to ensure that it is being used to enhance Māori and Pacific access to
HEHA programmes.
7. An increased emphasis on the production of high quality evaluations is required
to enhance the evidence base for initiatives. We recommend evaluations should
be undertaken to develop case studies of food industry initiatives; in addition, all
evaluations should contain information about funding sources and value for
money outcomes.
8. Further population data collection is essential in order to monitor nutrition and
physical activity behaviours and environments, as well as body size. Data from
New Zealand Health and Nutrition Surveys, and the Nutrition and Physical
Activity Survey must be examined in order to assess obesity, physical activity
and nutrition related outcomes.
18
Introduction
A worldwide epidemic of obesity has been described since the late 1990s, with rapidly
increasing prevalence, particularly in the western world. (3, 4) In New Zealand, rates of
obesity and overweight have increased since the 1980s, particularly in Māori and
Pacific people and those living in deprived areas.(1). The 2006/7 New Zealand Health
Survey reported that 29% of NZ children aged 2-14 years and 63% of NZ adults were
classified as overweight or obese. (2)
The World Health Organization’s Global strategy on diet, physical activity and health was
launched in 2004 in response to concern over increasing rates of non-communicable
disease. It places the responsibility for improving diet, and increasing physical activity
in populations across sectors, and calls for governments to develop national strategies
and actions plans on diet and physical activity.(5) New Zealand’s Healthy EatingHealthy Action: Oranga Kai - Oranga Pumau (HEHA) Strategy (‘the Strategy’) was
launched in 2003 to address growing concerns over poor eating habits, lack of physical
activity, and the associated prevalence of obesity and increased risk of adverse health
outcomes that result. Within a framework that recognises the importance of the Treaty
of Waitangi and of reducing inequalities in health in New Zealand, the Strategy
introduces a vision where there is:
‘an environment and society where individuals, families and whānau, and
communities are supported to eat well, live physically active lives, and
attain and maintain a healthy body weight’.(6)
The HEHA Implementation Plan for 2004 - 2010 uses the methods of health promotion
action of the World Health Organization’s Ottawa Charter for Health Promotion(7) to
define a series of proposed approaches and specific actions, as well as identifying key
population groups of Māori, Pacific and lower socioeconomic groups as well as children,
young people and families/whānau.(8)
An overarching intervention logic for the strategy has been established, delineating the
broad steps for creating the changes envisaged by the HEHA Strategy and
Implementation Plan. (9)This is shown in Figure 2.
19
Figure 2 HEHA Strategy Overarching Intervention Logic(9)
The HEHA work programme covers seven areas:(9, 10)
 Leadership and coordination at both national and district levels
20






Activities in schools and early childhood settings, including the Fruit in Schools
programme. Initiatives 1 and 2 of the Mission-On campaign also link with HEHA
work in schools and ECE settings (including Ministry of Education Food and
Nutrition Guidelines, Ministry of Health Food and Beverage Classification System
and the Nutrition Fund)
Breastfeeding initiatives, including a social marketing campaign, DHB breastfeeding
action plans, and work on breastfeeding workforce development
Communication to engage stakeholders and raise the profile of HEHA and its key
messages at both district and national levels (the latter including the Feeding our
Futures and breastfeeding social marketing campaigns; HEHA network; and HEHA
newsletter)
Primary health care, including the development and implementation of national
guidelines for the management of overweight and obesity, and an innovations fund
to support community action to improve nutrition, increase physical activity and
reduce obesity in high-needs groups
Working with the food and advertising industries to improve the nutrition
environment, including the production, supply and marketing of food
Monitoring, research and evaluation of HEHA initiatives and outcomes.
In addition to the direct HEHA work programme, a number of other national and
district programmes contribute to the implementation of HEHA, such as the Mission-On
campaign, SPARC’s Push Play, the Mangere Healthy Kai programme, Ngati & Healthy on
the East Coast, and Capital & Coast DHB’s Shake It, Beat It, Learn It Pacific initiative.(9) A
number of key informants referred to aspects of Mission-On during their interviews.
This was an inter-agency campaign, coordinated by SPARC in partnership with the
Ministries of Health and Education and with support from the Ministry of Youth
Development. Mission-On was launched in September 2006, and discontinued in mid2009. There were 10 initiatives aimed at improving the nutrition and physical activity
of children and young people from birth to 24 years old. The initiatives and their
overlap with HEHA are shown in the diagram below:
21
Figure 3 Relationship between HEHA and Mission On projects (Source Ministry of Health HEHA team
personal communication)
22
An outline of developments related to HEHA is shown in Table 1 HEHA Strategy Timeline below.
Table 1 HEHA Strategy Timeline
Year
2002
2003
2004
Date
Activities
February
Release of Healthy Action – Healthy Eating Oranga
Pumau – Oranga Kai: A Draft for Consultation
December Summary of feedback on draft strategy
March
Release of Healthy Eating – Healthy Action Oranga Kai
– Oranga Pumau: A Strategic Framework 2003 and
Healthy Eating – Healthy Action Oranga Kai – Oranga
Pumau: A Background 2003
June
Release of Healthy Eating – Healthy Action Oranga Kai
– Oranga Pumau: Implementation Plan: 2004-2010
July
Tripartite Agreement signed between the Ministry of
Health, Ministry of Education and SPARC (ended in
2007)
September Food Industry Accord signed
October
External Coordination Group established
2004/05
Realignment of existing funding for nutrition and physical
activity to meet actions set out in The HEHA Strategy
Implementation Plan
2005
Term 4
2005/06
2006
Funding Allocations
Phase 1 of Fruit in Schools begins
Allocation of the Cancer Control Action Plan funding for
HEHA
Term 2
June
Phase 2 of Fruit in Schools begins
Permanent HEHA Project Team at Ministry of Health
in place
September Launch of Mission-On
October
Crown Funding Agreements in place with DHBs for HEHA,
including funding to support DHB Project Manager roles
Term 4
Phase 3 of Fruit in Schools begins
23
2006/07
2007
January
February
March
April
May
May
May
July
July
August
November
2007/08
2008
January
April
May
June
July
New on-going funding allocated to HEHA
Establishment of DHB HEHA Project Manager
positions
First meeting of Inter-Agency Steering Group on
HEHA
Release of Healthy Eating – Healthy Action Oranga Kai
– Oranga Pumau: Progress on implementing the HEHA
Strategy 2007
First DHB Ministry Approved Plans (MAPs) due with
MoH for 2007/08 (first draft; final draft due in June
following MoH feedback)
Feeding our Futures campaign launched by the Health
Sponsorship Council in partnership with Agencies for
Nutrition Action
Community Action Plan funding announced in Budget
Two clauses added to the National Administrative
Guideline (NAG) 5 requiring Boards of Trustees to
“promote healthy food and nutrition for all students;
and where food and beverages are sold on school
premises, make only healthy options available”
Breastfeeding campaign launched
Food and Beverage Classification launched
Release of the Health Select Committee Inquiry into
Obesity and Type 2 Diabetes in New Zealand
Release of Government Response to the Inquiry into
Obesity and Type 2 Diabetes 2007
Additional on-going funding allocated to HEHA
Establishment of DHB HEHA District Coordinator
positions
Second DHB MAPs due with MoH for 2008/09 (first
draft; final draft due in June following MoH feedback)
Establishment of Sector Steering Group
Development of HEHA network begins
Launch of the first phase of the breastfeeding social
24
November
2009
February
June
marketing campaign
Release of Healthy Eating – Healthy Action Oranga Kai
– Oranga Pumau: Progress on implementing the HEHA
Strategy 2008/09
Removal of NAG 5 clause iii (“where food and
beverages are sold on school premises, make only
healthy options available”)
Green Prescriptions to transfer from SPARC to MoH; Funding for District Coordinators, Mission-On and Feeding
other Mission-On programmes discontinued
our Futures ends. Public Health Unit baseline
nutrition/physical activity funding, DHB evaluation budget,
HRC research partnership funding all reduced. Nutrition
fund merged with Community Action Project funding.
25
The pre-existing structures which supported work on nutrition and physical activity
prior to HEHA are shown in Figure 4 below, followed by Figure 5 which shows the new
enabling infrastructure introduced by HEHA. The major new components were an
expanded, dedicated HEHA project team within the Ministry of Health; additional
funding channelled through District Health Boards; and the creation of two new
positions within DHBs (a HEHA Project Manager and District Coordinator).
Figure 4 Nutrition and Physical Activity Infrastructure 2003
Ministry of Health
New Zealand Health
Strategy 2000
13 population health priorities,
including:
Improving nutrition
Improving physical activity
Reducing obesity
District Health
Boards (21)
Public Health Units
(12)
Non-Governmental
Organisations
(NGOs)
Some services
encompassing
nutrition and
physical activity
Public health
services,
including
nutrition and
physical activity
programmes
Nutrition and
physical activity
programmes
Sport and Recreation
New Zealand (SPARC)
Regional Sports
Trusts
Physical activity
programmes
26
Figure 5 Nutrition and Physical Activity Infrastructure Under HEHA
Ministry of Health
Advisory Groups
New Zealand
Health Strategy
2000
External Coordination
Group 2004-2006
Interagency
Steering
Group 2007
Sector Steering Group
2008
HEHA Strategy 2003
HEHA Implementation Plan 2004
Ministerial Advisory
Group 2008
Sport and
Recreation New
Zealand (SPARC)
Māori and Pacific
Caucuses
Public
Health
Operations
Office of the
Director of
Public
Health
Expanded
HEHA Project
Team
Central
Government
Agencies
Nutrition and
Physical
Activity
Policy
Mission-On
2006-09
District Health
Boards (21)
Public Health
Units (12)
HEHA project
manager & district
coordinator
HEHA Ministry
Approved Plan
Fruit in Schools
NonGovernmental
Organisations
(NGOs)
District HEHA Action Groups
and HEHA initiatives, including:
DHBs, PHOs, local and central
govt, NGOs,
(Ministry of Health, SPARC,
Ministry of Education, Ministry
Youth Development)
Health
Sponsorship
Council
Feeding our
Futures campaign
Regional
Sports Trusts
Directly funded
initiatives e.g.
breastfeeding,
FBCS support
Physical activity
programmes
Evaluation of the HEHA Strategy
Because the HEHA Strategy emphasises evaluation and creation of an evidence base for
future initiatives, the Ministry of Health has commissioned a consortium of researchers
to evaluate the HEHA strategy. The Consortium comprises researchers from the Centre
for Translational Research into Chronic Diseases (CTRCD) who are situated at the
University of Otago and the Auckland University of Technology (AUT), and Victoria
University’s Health Services Research Centre (HSRC).
While there is increasing evidence of effective interventions(11, 12), and systematic
reviews of programmes to improve nutrition, increase physical activity and reduce
obesity(13-16), evidence for strategies and interventions to reduce obesity at a
population level is lacking. (14, 17)
“[T]here are as yet no models to follow because no country has yet developed and
implemented a coherent programme of action to prevent further weight gain in the
population and to manage its current obesity burden.” (18, p24)
The Evaluation of the HEHA Strategy will address this gap in the international
literature.
To reflect the HEHA strategy, four evaluation questions have been identified:
27
1. Implementation– How was the strategy implemented and how did this connect
with policy, improvement, and across government integration?
2. Outcomes– How has the strategy been associated with changes in population
prevalence of physical activity and nutrition behaviours, weight status, and
environments associated with these?
3. Improvement– To what extent has the strategy implementation been improved
as a result of learning through both practice along the way, and as a result of the
strategy evaluation itself?
4. Value for money– How have outcomes as a result of investment in various
components of HEHA been associated with mid and higher-level outcomes.
What sort of value can be attributed to each investment?
Conceptual Framework
As part of the evaluation of the HEHA Strategy, the evaluation team has developed a
conceptual framework to frame and guide key aspects of the evaluation. The conceptual
framework recognises that the HEHA Strategy takes an ecological approach,
acknowledging that environmental and socio-demographic factors influence nutrition,
physical activity, and obesity. It draws particularly on the Treaty of Waitangi, He
Korowai Oranga-the Māori Health Strategy(19), the Ottawa Charter for Health
Promotion(7), and the Pacific Health and Disability Action Plan(20). It also recognises
that the Strategy has both horizontal and vertical complexity (21), particularly where
the different organisations and agencies that are to implement the Strategy have a range
of goals and responsibilities beyond improving health; recognises that the Strategy is
dynamic and thus may be influenced by changing political and social contexts (see for
example(22)); and draws on a number of different conceptual theories which will be
used to frame and guide this evaluation from an evaluation perspective.
Full details of the framework are included as Appendix 2; a summary is provided here
in order to better introduce the approach being taken throughout the evaluation. The
key components of the conceptual framework relate to:

Māori health – where the evaluation recognises the importance of the Treaty of
Waitangi to New Zealand policymaking and reflects the Treaty of Waitangi
principles of partnership, protection and participation in the evaluation process.
More specifically, the evaluation recognises the importance of Māori values, needs
and aspirations to policy processes and interventions. (6, p.56) Evaluation of the
HEHA Strategy thus requires a Māori lens that can examine how Māori-specific and
mainstream initiatives have involved Māori and improved Māori health outcomes.
Drawing on He Korowai Oranga: the Māori Health Strategy, as well as on Mason
Durie’s Te Pae Mahutonga,(23)Hua Oranga, (24)and He Taura Tieke(25), a set of
seven evaluation principles have been identified, through which the Māori
objectives of HEHA can be considered in a comprehensive and culturally aligned
manner. The key principles are: Māori Development; Māori Autonomy; Māori
28
Delivery; Māori Leadership; Māori Integration; Māori Environmental Perspectives;
Māori Responsiveness (see Appendix 2).

Pacific Health – the HEHA Strategy recognises the importance of reaching Pacific
peoples, who are disproportionately affected by obesity-related health problems.
The Pacific evaluation framework (see Appendix 2) has been informed by the
principles of the Pacific Health and Disability Action Plan and on a ‘Fono Fale’ model,
and the Ottawa Charter. This Pacific model of health uses the metaphor of a Samoan
fale or house with the roof representing cultural values and beliefs; the foundation
representing the family or community; the four pou or posts connect the culture and
family and interact with each other. The four pou include the following dimensions:
spiritual; physical; mental and emotional, and other factors, such as gender, sexual
orientation, age, social class, employment and educational status, which can affect
health.(26)

Ottawa Charter for Health Promotion – the evaluation conceptual framework
recognises that the HEHA Strategy and Implementation Plan are based on the
Ottawa Charter for Health Promotion.(7)The Ottawa Charter’s five strategies for
action which form the basis of the HEHA Strategy’s objectives also form a key
component of the conceptual framework for the Evaluation.

Evaluation Theories – the evaluation conceptual framework draws on key
theories of programme evaluation, incorporating aspects of both Realistic
Evaluation (27) and Theories of Change approaches to evaluation.(28) These
approaches recognise that social programmes take place in diverse contexts and
that the interrelationships, institutions and structures of the contexts into which a
programme is introduced all shape its outcome. A realistic evaluation framework
enables separation of the contexts, mechanisms and outcomes associated with a
programme of change such as the HEHA Strategy. Because they investigate
mechanisms for change within their contexts, realistic approaches also allow for the
dynamic nature of both the Strategy itself and the contexts within which it is
implemented.The Theories of Change approach aims to identify and assess the
theorised relationships between the context for the Strategy; the Strategy itself, its
implementation, and the initiatives undertaken; and the desired outcomes, and then
to evaluate how each aspect of the Strategy and its implementation works in
practice, leading to conclusions about how well each aspect of the Strategy and its
implementation is contributing to the overall Strategy outcomes. Thus, the
evaluation will support an exploration of the factors promoting or mitigating against
the appearance of specific outcomes.

Value-for-Money - the conceptual framework also recognises that the evaluation
must answer key questions around whether or not the Strategy and its
implementation have resulted in value-for-money. This aspect of the evaluation will
focus on three key issues. First, we aim to assess the effectiveness of the HEHA
initiatives in achieving immediate, intermediate, and long term outcomes, and to
thereby identify the benefits(outputs and outcomes) from the HEHA Strategy, and to
29
compare these with the costs associated with the implementation of the HEHA
Strategy, that is, with the resources (inputs) used in implementation. Second, the
value-for-money aspect of the evaluation also aims to identify whether or not
greater benefits might have been obtained from alternative uses of the resources
used in implementing HEHA. Third, the evaluation will consider the institutional
context within which HEHA has been implemented, and the incentives, which
operate for different agencies, involved in the implementation of HEHA, in order to
assess whether the institutional arrangements are supporting or detracting from the
implementation of HEHA.
Using the Conceptual Framework in the Evaluation
The Conceptual Framework, set out and discussed in some detail above, has played an
important role in framing key aspects of the evaluation. It provides guidance for the
overall design of the evaluation, including the need to examine contexts, mechanisms
and outcomes and the linkages between these; it clearly identifies the importance of
Māori and Pacific, and Ottawa Charter, perspectives to the evaluation; and recognises
the need to collect data at a number of different levels (national and district) and from a
wide range of key stakeholders.
More specifically, the evaluation has drawn on the conceptual framework in a number
of ways; that is, it has guided:
 the identification of key stakeholders involved with the HEHA Strategy and for the
HEHA Strategy evaluation
 the development of interview schedules for the key informant interviews, which are
a key means of collecting data for the evaluation, especially in its early stages
 the analysis of interview and document data, with the Māori and Pacific frameworks,
and the Ottawa Charter, in particular, being used to analyse data where appropriate
 the coding schedule for the stocktake of initiatives, in order to report on the mix of
initiatives which are being implemented as a result of the HEHA Strategy
 the design of the review of evaluations and the development of a framework for
identifying useful information from evaluations of individual initiatives
Workstreams
Components of the Evaluation
In order to answer the Key Evaluation Questions, the evaluation methods plan has
identified the following components for the evaluation:
1.
Engagement with Key Stakeholders throughout the evaluation– To assist the
research team to obtain contextual information, develop relationships and
30
develop methods to keep key stakeholders informed of the evaluation progress
and findings.
2.
Key Informant Interviews and Document Analysis – In order for the research team
to understand the implementation of the HEHA strategy. Key informant
interviews will government, DHB, NGO, PHO, Māori, Pacific, and other national
and local stakeholders. Document analyses will be undertaken to understand
HEHA strategy implementation, especially stakeholder engagement with HEHA.
3.
Quantitative Measurement and Analysis of Outcomes – To measure physical
activity, nutrition behaviours, and food, nutrition, and physical activity
environments, and body size and changes over time during the HEHA strategy
implementation period.
4.
Stocktake of Initiatives and Review of Existing Initiative Evaluations – A stocktake
of initiatives will be undertaken to assess the mix of initiatives and the resources
allocated to HEHA implementation goals and to enable subsequent judgements
about value-for-money. A review of existing evaluations will also provide
information about the quality of evaluations being undertaken in relation to
HEHA and about the outcomes being obtained from individual HEHA initiatives.
5.
Comparison and Interpretation of findings using high quality sources of data – The
use of multiple high quality datasets generated from different research
methodologies such as the outcomes data, the implementation interviews and
document analyses, and the stocktake and review of initiatives will allow a more
robust and defendable assessment of those HEHA activities that are working, and
those that are not. This area of activity includes assessment of value-for-money
and an assessment of the costs and consequences of the Strategy.
6.
Dissemination of evaluation findings throughout the evaluation – Delivering
regular feedback and reporting to the Ministry of Health and key stakeholders is
important for the continuous improvement methodology used in the HEHA
implementation strategy and more widely in health promotion. The evaluation
team will provide regular stakeholder feedback through an annual evaluation
bulletin and through formal annual reporting requirements to the Ministry.
This is the first interim report for the HEHA Strategy Evaluation. It contains
preliminary analysis of implementation of the HEHA Strategy, and outlines plans for
further analysis for future reports. In particular the following subsequent reports are
planned:
 November 2009: First Full Value for Money Analysis
 November 2011 Final Evaluation Report
31
Section 1: Implementation
Summary
-
This section focuses on assessing implementation of the HEHA Strategy to date. It
also provides information on how the Strategy’s implementation may be
improved.
-
Data was collected through interviews and focus groups with key informants
(from the Ministry of Health, other government agencies, DHB and Public Health
Unit personnel in HEHA-related roles, national NGOs and Pacific policymakers)
and from an analysis of key documents.
-
The Ministry of Health is generally recognised by key informants to be leading the
Strategy effectively, although some DHB participants consider the Ministry of
Health is sometimes too prescriptive about implementation and could
communicate better about impending changes. DHBs view themselves as the local
implementers of the Strategy, but the need for this layer is questioned by some
NGO key informants. Some NGO key informants are also concerned about the role
and influence of the food industry in the implementation of the HEHA Strategy.
-
All key informants agree on the importance of collaboration for the success of the
Strategy yet do not always find this easy in practice, but recognise that it needs
time and trust to develop. The Ministry of Health itself is seen to need better coordination across all the Directorates that have a role in HEHA. Good
collaboration seems to have developed between the Ministry of Health, the
Ministry of Education and Sport and Recreation New Zealand (SPARC), in part
due to the mandate from their Ministers to work together on Mission-On
initiatives (also including the Ministry of Youth Development), and because of an
earlier formal Tripartite Memorandum of Understanding, which has now ceased.
Inter-governmental collaboration on HEHA beyond these agencies seems less
well developed at this stage, and there is a need to build stronger linkages
around shared issues.
-
DHBs are developing collaborative relationships with local stakeholders, more
easily in the case of smaller DHBs and those with a stronger pre-existing
population health focus. Good collaboration between agencies at a national level
is also reported to help facilitate local relationships. An NGO key informant
questioned the need for DHB HEHA project managers and some existing
community groups and some Public Health Units were initially suspicious of the
new role.
-
Engagement with the priority groups identified by the Strategy – Māori, Pacific,
children and families, and lower socio-economic groups – is a focus for the
32
Ministry of Health and DHBs, although not all other government agencies focus
their work on these particular groups. Effectiveness of partnerships between
DHBs and Māori and Pacific peoples seems to be variable. The need for
community level engagement is emphasised by the requirement that DHBs
engage with these groups and include them in governance. The focus on children
and families is through work in the education sector. Engagement with lower
socioeconomic groups is less direct than with the other priority groups, being
expressed mainly through work in low decile schools and in some overlap with
Māori and Pacific work.
-
DHBs have used their usual planning processes and appear to have consulted
widely to develop HEHA plans for their districts. However the required Ministry
Approved Plans were perceived to be complex and time consuming. On-going
integration of HEHA into the general District Annual Plan is preferred by many
DHB key informants.
-
Implementation activities encompassing the Strategy’s six approaches for action
are reported, and all are considered by informants to be a necessary part of
HEHA’s multi-faceted approach. However there is most support, across key
informants, for ‘working to ensure healthy policy’ and ‘creating supportive
environments’ to make behaviour change easy, although in practice some have
indicated that it may be easier to focus on ‘developing personal skills’.
-
The Ministry of Health reports close alignment of implementation with the
Implementation Plan, although DHBs and other sectors seem to be working more
from their own planning documents. On-going workforce capacity building is
recognised by many to be needed to support HEHA implementation.
-
A wide variety of means are being used to encourage the continual sharing of
new learning about HEHA among stakeholders, including a bimonthly
newsletter, e-mail updates, the on-line HEHA Network and Knowledge Library,
and the HEHA evaluation Toolbox.
-
Key informants identified two main outcomes of HEHA to date. The first is
increased awareness in society of the problem of obesity and the need for good
nutrition and exercise. The second is changes in the school and pre-school
environment. There is little specific evidence to quantify changes to date. Key
informants believed outcomes from HEHA may be difficult to measure, need time
to eventuate, and may be hard to attribute specifically to HEHA. Creating
supportive environments in schools, leadership and collaboration were
identified by key informants as factors contributing to successful change.
-
The Strategy may be improved by continuing to build engagement and
collaboration, with the Ministry of Health building stronger links with NGOs,
some government agencies, and with local government. NGO key informants
would like to see more action on environmental change, while DHB key
33
informants seek certainty about the future direction and funding of HEHA and
would like more flexibility in how they can implement the Strategy.
-
Pacific policymakers reported a lack of consultation in the early stages of the
Strategy development, although this has subsequently improved, particularly
with the appointment of a HEHA Target Champion and through engagement
around Community Action projects. Pacific policymakers consider Pacific
leadership at all levels of HEHA is important.
-
Pacific policymakers and key informants felt workforce development was
important to enable Pacific communities to determine their own needs and
empower them to take action (as has happened with the Community Action
projects), rather than telling them what to do. Moreover, sustainability of this
workforce was also considered important through encouraging those who
undertake nutrition classes to consider long-term career goals beyond initial
training.
-
Pacific key informants also noted that there are costs for members of the Pacific
community who give time to HEHA meetings which need to be recognised and
compensated.
-
Key informants considered that the initial implementation of HEHA had resulted
in several positive outcomes for Pacific people, including more people exercising
and healthier food being served at some community gatherings, although they
considered that there was less change at large community celebrations and
serving portions might still be too big. Key informants have suggested that
awareness within Pacific communities about HEHA issues has grown, and there
is community support for change. However, evidence to measure Pacific
outcomes or changes in inequality is seen to be lacking, and monitoring of this is
needed.
Introduction
A key part of this evaluation is to assess the Implementation of the HEHA Strategy. This
is especially important in the early stages of the evaluation, as to date no formal
evaluation of the implementation of the Strategy has taken place. In this section of the
report, we set out the Research Questions we are focusing on; the methods used for this
part of the evaluation, including an overview of the key informant interviews and
document analyses which form the basis for this part of the evaluation; our findings to
date; a discussion of the findings; and conclusions and recommendations.
34
Research Questions
The Key Evaluation Questions around implementation are:
Implementation Focus
1. How has the HEHA Strategy been implemented?
 Did the implementation process result in
 collaborative and co-ordinated networks and partnerships across
stakeholders and across sectors?
 increased stakeholder participation and involvement in developing
and implementing actions that support the HEHA objectives?
 active engagement and participation of priority populations
(Māori, Pacific peoples, children young people and their whānau,
and lower socio-economic groups) in these networks and
partnerships?
 Has implementation contributed to the development of a learning
environment? How has it done so?
 To what extent have stakeholders found the process of implementation
acceptable?
 Is/did the implementation process leading to development and
implementation of actions addressing the key areas of change (in the food
and physical activity environments and behaviours) across sectors,
regions, communities, organisations, settings, whānau, and individuals?
 Did implementation align with Implementation Plan? What variations /
modifications occurred? What were the reasons for the changes? Were
those variations / modifications successful?
2. What was the type (policy response type), spread, mix and level of
implementation? What was the collective pattern of implementation?
Outcome Focus
3. What changes occurred as a result of the implementation of the HEHA Strategy?
Improvement Focus
4. What changes are required to the HEHA Strategy and its implementation to
better achieve the Strategy’s vision and goals?
Further information on Question 2 is also included in Section 4: Stocktake of Initiatives.
35
Baseline quantitative data about outcomes (Question 3) is presented in section 2,
Population Data.
Methods
The aim of this part of the evaluation is to explore issues relating to the implementation
of the HEHA Strategy, in order to answer the key evaluation questions set out above. We
have used three main data sources for this part of the evaluation: key informant
interviews; document analysis; and a stocktake of HEHA initiatives. For later reports,
we will also draw on the review of evaluations to provide further information about the
implementation of the Strategy.
Key informant interviews and Focus Groups
The purpose of the key informant interviews and focus groups was to examine key
stakeholders’ perspectives of the implementation of the Strategy to date, and to identify
where improvements could be made in further implementing the Strategy over the next
few years. The use of qualitative interviews allows for in-depth discussion of topics by
key informants (29, 30) giving voice to their own experiences and views (29, 31, 32)
The research team developed a Stakeholder Framework to guide the selection of key
informants who might participate in interviews or focus groups, in order to focus this
part of the research on the key groups working to implement HEHA. Key informants
included:

Central government agency informants, including the Ministry of Health, other
government agencies playing a major role in the Strategy (Sport and Recreation
New Zealand (SPARC), Ministry of Education (MoE)), and other government
agencies whose activities potentially can also lead to improvements in nutrition
and physical activity and reductions in obesity,

District Health Board HEHA Project Managers (who are overseeing HEHA
implementation at DHB level) and District Co-ordinators (who work with
schools); Funding and Planning Managers; Māori and Pacific managers (where
the DHB has these positions).

National non-government organisations (NGOs) who also work on HEHA-related
activities.
We used a snowball approach to identify other informants for interview by asking key
informants who else they felt could contribute information for the evaluation (33).
For later reports, we will also interview key stakeholders at community level, to identify
their views on the implementation of the Strategy.
Ethics approval for the research was gained from the Multi-region Ethics Committee
(MEC/08/56/EXP). The research team developed generic interview/focus group
schedules based on the key evaluation questions and the conceptual framework which
36
guide the evaluation; these were then adapted for the different roles that stakeholders
play in implementation (see Appendix 3). The interviews were semi-structured,
designed to cover the research topics using open-ended questions, allowing participants
to express their views in response to the questions as well as raise other issues of
importance to them.
We contacted key informants to seek their participation in the evaluation, and
interview/focus group schedules were sent to the informants prior to the interview in
order for them to be able to think about the issues we wished to cover before the
interview/focus group. Written consent was obtained from the key informants to
participate in the evaluation and all interviews/focus groups were taped with the
participants’ consent. About two-thirds of interviews/focus groups were conducted face
to face and the remainder were done by telephone. We aimed to keep the interviews to
around one hour, and focus groups to an hour and a half; in a few cases, it was not
possible to cover all interview questions in the time available. Two participants chose to
send written responses only, and a few participants sent additional written information.
Almost all those approached agreed to participate, although there were some potential
informants who felt that their engagement or knowledge of HEHA was limited and that
they therefore did not wish to participate. It is possible we have therefore missed the
opportunity to understand why some organisations have not felt well engaged with
HEHA, despite it appearing they could have a contribution to the Strategy.
Originally, we had intended for a number of key informants, at DHB level in particular,
to be able to be interviewed through the use of focus groups, making use of
opportunities when meetings involving several DHBs took place. In some areas, this was
able to be arranged within the timeframe of the data collection (January to April 2009)
while in other DHBs, it was necessary to conduct interviews with individual key
informants representing individual DHBs.
Almost all participants seemed to comment quite freely, whether interviewed alone or
with others. In two instances where it was felt one person had not been able to
contribute easily within a group, they were followed up afterwards and given the
opportunity to make additional comment of their own. Focus groups and interviews
with more than one person tended to provide additional examples as informants
responded to each other’s comments.
We undertook a total of 63 interviews and five focus groups as set out in Table 2
37
Table 2: Key Informants
Number of
Interviews
Ministry of Health
Other Government Agencies
DHBs (Funding & Planning
Managers, HEHA Project
Managers, District
Coordinators and some other
HEHA team members)
Public Health Units
NGOs
Pacific Policymakers (MoH,
other government agencies,
DHBs)
Māori key informants
Total:
Written
Response
Only
1
-
Total Number
of Participants
9
6
14
Number of
Focus
Groups
5
9
5
10
-
1
-
14
6
10
10
63
5
2
105
11
7
47
Most individual interviews and focus groups were transcribed; in a small number, the
tapes were used by the interviewer to extract key themes, which were written up as
interview notes rather than full transcripts. Where requested, we sent transcripts or
notes back to each key informant interviewee or focus group participant for them to
make any changes they wished. About half those who requested their transcript/notes
made changes, generally minor editing, and sometimes adding additional points. A small
amount of material was removed from transcripts, but this did not affect the overall
analysis.
We analysed each transcript using a thematic approach(34). That is, we reviewed each
transcript in relation to the key questions in the interview schedule and the conceptual
framework. We also identified any additional issues brought up in relation to HEHA in
the interviews not covered in the questions or the conceptual framework. We compared
and contrasted the information analysed in this way across key informants, in order to
identify similarities and differences in the views of the different stakeholders. Some of
the findings have also been able to be compared with data from other parts of the
evaluation, as well as with documentary sources. Further comparisons will be done as
the evaluation progresses.
Because of the nature of semi-structured qualitative interviewing, participants may not
cover all the questions in the interview schedule and they may discuss additional topics.
Hence it is not possible to quantify the degree to which views are held. However, we
have tried to present the themes which generally arose from the data analysis and avoid
emphasising uncommon opinions. Nevertheless, in some instances, we have reported
single responses where these provide important viewpoints or contrast with a majority
opinion. It is important to understand such divergent material (30), and some of these
issues raised will be explored further in our later interview rounds.
38
In the write up of the findings below, we have structured the material around the key
evaluation questions and around key aspects of our conceptual framework. Key
informants have been identified in general terms only (e.g. “DHB key informants”), and
only where it is important to give context to the source of a comment.
Document Analyses
We have also examined a number of key documents to provide further information on
implementation of the Strategy. These documents have included:
 HEHA Strategy(6)
 HEHA Implementation Plan 2004-2010(8)
 HEHA Implementation Progress Reports (2007, 2008/09)(9, 10)
 DHB Ministry Approved Plans (MAPs) for 2007/08 and 2008/09
 Ministry of Health Business Plan (2007/08)
 Cabinet documents relating to HEHA
 Health Select Committee Report, 2007 (22)
 Government Response to the Health Select Report, November 2007 (35)
 Ministry of Health feedback on MAPs for 2008/09.
 Tripartite meeting minutes
 Māori caucus meeting minutes
 HEHA External Coordination Group meeting minutes
 Inter-Agency Steering Group on HEHA meeting minutes
 Sector Steering Group meeting minutes.
Documents were analysed using a thematic approach as set out above. The document
analyses have been used to inform a HEHA Strategy timeline, to provide background
information on the HEHA Strategy and its implementation (both set out in Appendix 3),
and to further inform the findings from the key informant interviews/focus groups set
out below.
Stocktake of Initiatives
The stocktake of initiatives is the main means by which we are able to examine the
pattern of initiatives which have been implemented as a result of HEHA. Further
information on the stocktake is set out in Section 3.
Results
The results are now presented under implementation, outcomes and improvement
sections, followed by the findings from Pacific key informant interviews.
39
1. Implementation
a. Leadership
All key informants saw the Ministry of Health as being the overall leader of the Strategy,
needing “to create that momentum, that impetus, that leadership for action…and helping
to create the broader environment in which all the other actions can take place.”A
number of aspects to their leadership role were consistently identified. The first is
policy setting, including having the vision and courage to take action on an issue even
when all the evidence may not be available. However the Ministry cannot set policy
independent of the Government’s desired direction.
Other Ministry leadership roles identified by key informants were having overall
responsibility for planning and developing the Strategy in collaboration with others
(with ongoing revision), then facilitating and supporting its implementation. This
includes continuing collaboration and co-ordination, funding and evaluation. Gathering
evidence and ensuring information is shared are also considered important.
While other government agencies saw they have a role in HEHA, it was still seen to
fundamentally belong to ‘health’, and one speaker commented, “I think it’s been quite
difficult for them, because while it’s core business for them, it’s not necessarily core
business for the stakeholders that they need to help them with it.”
DHB key informants generally considered the Ministry of Health is providing good
leadership. Most DHB key informants considered the Ministry was giving them good
support around the Strategy, but two felt the relationship is more that of funderprovider: “I have to say it is not a supporting role…it has a funder function and a
reporting function.” One DHB key informant commented they sometimes had the feeling
the Ministry considered the HEHA co-ordinators as its employees, when “No, you’re
funding us to employ them, so you can’t direct my staff to do stuff no matter it might be
convenient.” Some DHB key informants feel that HEHA has been too prescriptive at
times and has not allowed sufficient local flexibility; on the other hand, NGOs have to
work with 21 DHB variations and would like better communication and co-ordination
between them. In some instances, there could also be better communication about what
is happening to avoid duplication of work; an example being a DHB undertaking some
work locally, then later discovering the Ministry of Health was also working on the issue
nationally.
DHB key informants saw their role as implementing the Strategy, taking the national
direction and tailoring it to local needs. Being the intermediary between the Ministry of
Health directives and local community needs and aspirations was sometimes “a difficult
road to tread”. Local co-ordination is an important aspect of DHB leadership, and they
have responsibility for ensuring funding is being used well and making a difference.
Several key informants from Public Health Units spoke positively about the DHB role of
facilitating collaboration and coordination within a region and giving strategic direction
to nutrition and physical activity work. However, two wished to see DHBs having a
40
funding and planning role only, whilst leaving delivery to existing providers (such as
Public Health Units), building on what already exists rather than creating something
new. One NGO key informant questioned the role of DHBs, and whether there is a need
for “another layer of bureaucracy”, with a preference that Ministry of Health funding go
directly to organisations already working in the area.
All key informants were asked where they saw the key leadership for HEHA coming
from. While, as noted above, the Ministry of Health may have the primary leadership
role nationally, and DHBs at a district level, leadership across all sectors and levels
involved with HEHA was thought to be necessary. This included political leadership to
recognise the importance of the issues and to be willing to drive action, even though
there may not be quick results; leadership from local bodies to create healthy
communities; and communities themselves taking on the responsibility to bring about
social change. Academic input received one mention. Some NGO key informants
expressed some concern that the food industry is exerting too much influence on HEHA
and saw themselves as providing a “counterfoil” to that, although other NGO informants
indicated that they thought the food industry has a major role to play in improving
nutrition.
b. Engagement and Collaboration
The importance of engagement and collaboration for the HEHA Strategy
The HEHA Strategy states that to achieve its goals, “Co-ordination and collaboration is
required within the health sector, across other sectors and regions, between
government and non-government organisations, and involving both the public and
private sectors” (6, p.20). The Strategy also recognises that the health sector alone
cannot address all the necessary actions, as many determinants of health lie outside its
direct control (6).
Key informants were asked about their engagement (making meaningful connections)
and collaboration (actively working together) with partners to implement the Strategy.
Key informants agreed with the Strategy’s emphasis on collaboration and the need to
get buy-in across sectors and at different organisational levels:
I don’t think there’s any other way of addressing what’s a really complex issue.
Most of the big public health issues over the last three centuries have been issues
that the health sector identifies, but that the health sector can’t solve. So while it
can provide the impetus and the evidence and leadership, it isn’t something it’s got
the control to solve. So it can’t do it on its own.
Key informants identified a number of benefits of collaboration. Different organisations
and sectors contribute different areas of expertise, so “we end up building on each
other’s strengths.” Working together leads to better understanding about how other
agencies work, which means more appropriate actions are developed. It may be
possible to combine workforces and strengthen joint work, and a partner may be able to
facilitate access to different audiences: “it opens up doors which we wouldn’t have opened
up without that collaboration.” A District Coordinator believed collaboration and co-
41
ordination were particularly important in the education sector in order to “reduce the
noise” and “avoid confusion” from having multiple players approaching schools and early
childhood centres.
Key informants unanimously agreed that collaboration was “very important”, “crucial”
,“critical”, and “vital” for the success of the Strategy. However, they also thought that
achieving collaboration is not always easy, as one Ministry of Health key informant
explained:
I think working across sectors is always really difficult and even working within the
health sector can be quite fraught at times, 21 District Health Boards all with
different approaches and a whole raft of national, regional and local NGOs all with
the belief of what HEHA is and their part in it. So it’s an ongoing issue….in terms of
what a co-ordinated approach to HEHA implementation means…and requires
constant work.
It takes time to engage with partners and build trusting relationships and
understanding before the ‘work’ of collaboration can get underway effectively, as
another Ministry of Health key informant commented:
One of the things about collaboration is that it always sounds easy but it’s jolly
hard and it always takes a long time and I think you’ve got to make sure
everybody’s speaking the same language and at the same place before you start to
get any real benefits. So it looks like we’ve been talking to people for a long time
and not a lot’s happened, but if you don’t do that groundwork first and put the time
into the groundwork, you don’t get the bonus at the other end.
Engagement and Collaboration at a National Level
Key informants were asked about the Ministry of Health’s ongoing collaborative role.
Within the Ministry itself, there is collaboration between the designated HEHA team
and other parts of the Ministry with an interest in HEHA. One Ministry key informant
acknowledged the need “to present a better co-ordinated focus” between Directorates
within the Ministry. One DHB and one NGO key informant also commented on their
sense of poor communication between Directorates of the Ministry.
The Ministry of Health engaged with stakeholders in the development of the Strategy
and subsequent Implementation Plan (6, 8). To date, there have been three intersectoral
groups facilitated by the Ministry of Health, which have “changed in their nature and
membership over time.” The HEHA External Coordination Group was established in
October 2004, for two years, and included members from the Ministry of Health, other
government Ministries, DHBs, local government, NGOs and the food industry, and
Māori and Pacific members. The first meeting of the Inter-Agency Steering Group on
HEHA was in February 2007, with members from the Ministry of Health, other
government agencies and DHBs only. The current Sector Steering Group was formed in
2008 in response to a recommendation of the Health Select Committee Report in 2007
that “…an external advisory group be established to ensure that all stakeholders have
input into the national strategy” (22, p.30). It has two objectives: to provide expert
42
advice for implementing HEHA to a cross-ministerial Committee, and to facilitate
steering a whole-of-government approach to HEHA with strong input from the
stakeholders who are involved in implementing HEHA.(36) To address criticism that
some groups had been missed out earlier, the current Sector Steering Group has been
expanded.
The Ministry of Health also has an important role in engaging with other government
Ministries that have the potential to advance HEHA. The most effective intergovernmental collaboration, judging from key informants’ perceptions, seems to be that
between the Ministry of Health, Ministry of Education and Sport and Recreation New
Zealand (SPARC), particularly their joint working on ‘Mission-On’ programmes,
launched in 2006. This collaboration was driven by a directive on their joint Ministers:
“It was established through a single Cabinet paper that delineated ten initiatives and
exactly how they were to be delivered and by which agencies.” A joint Ministerial group of
the three agency Ministers plus an Associate Minister of Health and the Ministry of
Youth Development was established to govern Mission-On, who in turn work with a
joint officials group (including a partnership relationship with Te Puni Kōkiri) and some
inter-agency groups “that bring together what we’re doing so that we work consistently
and synergistically.” Project teams work on delivering the ten Mission-On initiatives,
with joint agency membership where initiatives are jointly delivered.
The initial Mission-On collaboration was thus mandated, but in practice, this
collaboration “…was difficult, it was unusual at first. It wasn’t something that people were
accustomed to doing, so I think we probably had to learn to do it in some respects which
you’d think would be obvious and easy, but it’s not.” Reasons for this included agencies
being used to working in their own “silos” with their own internal processes (such as
getting approval and sign-off to do something), and needing to learn and understand
each other’s “language and the culture and the issues that drive [each agency]”. The need
to pool funding and manage joint budgets was also mandated by Ministers, with funding
coming from existing budgets and being redistributed according to who was delivering
each programme, but again in practice, sharing funding had to be learned:
When an agency decides it’s going to do something universally, like reduce budgets
by 5%, I would have to step in and remind the agency that their money was not
their own, that it was part of a pooled fund, and without Cabinet approval, that
can’t happen.
Strong collaborative relationships were reported to have developed over time between
the Mission-On partners, both at national and regional levels. Mechanisms for
developing this collaboration included building personal relationships, using structures
such as joint meetings, and ensuring good communication and information sharing.
However, SPARC appears to have changed its views about its role in HEHA
implementation more recently. At the launch of the HEHA implementation plan in June
2004, the then Chief Executive Officer of SPARC said, “As you would expect, SPARC’s
role in the implementation of this strategy will see us focusing on its physical activity
components. We will provide leadership and take action to implement the plan” (37).
However currently, SPARC’s view is that it is not the lead agency for physical activity in
relation to health (but that this is the role of the Ministry of Health) – rather, “SPARC’s
43
primary focus for 2008-09 and onwards will be placed on physical recreation and sport,
rather than the wider sphere of physical activity” (38).
There may also be some differences between how the agencies view Mission-On and its
relationship with HEHA. One key informant said,
…we spent some time at the beginning of Mission-On’s life saying, ‘Well how does it
relate to HEHA?’ What I generally say is HEHA is the national strategy for the
country, run out of the Ministry of Health; Mission-On is a campaign that
contributes to those outcomes, but it’s run by a group of agencies, with a slightly
different structure. All of the people in the Ministry of Health who work on MissionOn do it under the umbrella of HEHA. So for them it’s a straight line, it’s a subset,
but for the others [participating agencies], not so much.
Differing perceptions of what is or is not HEHA are also noted in the value-for-money
section.
As well as the Ministerial mandate for Mission-On, another factor which aided
collaboration between the Ministries of Health, Education and SPARC was a formal
Memorandum of Understanding, or Tripartite Agreement which was formed in 2004.
This had “helped bring the departments together I suppose in the early days”, but over
time, some of the partners were reluctant to re-sign a formal agreement, so it lapsed in
2007, but was viewed as still being “alive” in terms of practical relationships. However
one person commented on the risk that without a formal agreement, there was no
longer any compulsion to work together and things could change if there is a change of
personnel or leadership among the agencies.
Collaboration between the Ministry of Health and other government agencies beyond
those involved in Mission-On seemed less well-developed and this was acknowledged
by the Ministry of Health as an area needing continuing work. One key informant noted
it was less easy to develop engagement with other agencies where it was not “driven
from the top” (as with Mission-On). One key to enabling inter-agency collaboration was
finding objectives and activities where there is shared incentive to be involved, and
building linkages around such issues. This involves understanding the drivers of other
Ministries, and finding areas in which health benefits will also meet their other aims. A
member of another government department also highlighted the need for the Ministry
of Health to target its collaboration with them to their areas of primary responsibility,
and not overload them with irrelevant information. In addition, building “person to
person” links was important. An example of collaboration around a mutual issue was
getting children to walk to school, as a Government key informant explained:
The energy conservation people were really keen to have people not driving their
cars to school because they want to save energy; you’ve got people in the transport
agency concerned about road accidents and they wanted to reduce those; and then
you had the Push Play team at SPARC really keen to increase activity among
children, and so that’s a natural fit.
At the same time, they added: “unless, I think, there is an explicit instruction from
Ministers that you are all tasked with this particular strategy, then people are not
necessarily going to see it as their responsibility.” This again highlights the necessity for
high-level leadership of the Strategy if it is to be effective.
44
Stakeholders also considered that collaboration was affected by who ‘owned’ the
Strategy and who is responsible for its outcomes. One Government key informant from
outside the Ministry of Health commented:
HEHA isn’t a list of instructions for anyone other than the Ministry of Health HEHA
team, but they obviously need key partners to see it actioned. What I’ve observed a
bit from the outside is that the other people contributing see their names and their
work in there and think, ‘Oh yeah, ok, I see how we are contributing to your
outcomes’, but they’re not necessarily owners of those… whereas the Ministry of
Health are owners of the strategy….Whereas with Mission-On, we are all the
owners together.”
A further factor which stakeholders perceived encouraged collaboration was the
availability of funding to support the collaboration. A Ministry of Health key informant
noted:
I’ve certainly found if you’re working with other agencies, if you want to make a
difference, if you’ve got money, then that certainly helps. If you go to them without
any money to contribute, like to a programme or shared things, there’s less of that
[willingness to work together].
Conversely, although the Ministry of Health may identify another agency as being the
ideal key leader for HEHA in a particular arena, they cannot direct another agency’s use
of resources - “if they through their mechanisms decide not to put funding into [it], you’re
sort of stuck. There’s not a lot you can do.”
DHB key informants generally reported good support and communication from the
Ministry of Health, although one said it felt more like a funder-provider relationship and
more personal engagement out in the district would be appreciated. Another criticism
was that, at times, DHBs have been working on HEHA resources or research which they
have not known is also being worked on in the Ministry, “So some duplication has
occurred unnecessarily due to lack of communication.”
Engagement and Collaboration at DHB Level
DHB key informants discussed their engagement and collaboration with other
stakeholders around HEHA within their districts.
DHBs were required to establish an intersectoral steering group to govern their HEHA
activities. A Ministry of Health informant noted:
We wanted DHBs to engage with senior people across a range of organisations who
could make decisions about funding, resource allocation, they could contribute in
concrete terms to the formation of a district plan that they could sign up to and
commit their agency to…So collaboration has been given a huge amount of
priority, I think, in implementation.
DHB key informants noted the quite prescriptive requirements from the Ministry of
Health to form several collaborative groups. The template for DHB’s first HEHA Ministry
45
Approved Plan (MAP) stated, “The Ministry requires DHBs to create and lead intersectoral District Healthy Eating-Healthy Action (“HEHA”) Co-ordination or Steering
Groups (“HEHA Group(s)”) which will have responsibility for planning, prioritising,
funding and monitoring HEHA initiatives in their districts. The HEHA Groups will have a
leadership role in implementing initiatives under HEHA at district level. The project
manager will establish and keep operating a HEHA Group that will facilitate and coordinate the work of stakeholder agencies. The group should include the Project
Sponsor, PHO representatives, Māori and Pacific representatives, education
organisations, regional sports trusts, local government, and communities” .(39, p12)
Draft terms of reference for this HEHA coordination group were also supplied with the
template. In addition, an education sub-group was to be established which would
“…focus on schools and early childhood education (“ECE”) centres by supporting the
effective implementation of the Nutrition Fund. Membership of the sub-Group must
include a Health Promoting Schools Advisor, Regional Sports Trust, Fruit In Schools
Advisor, NGO, schools representative, ECE representative, Maori and Pacific education
sector representatives, and DHB HEHA Project Manager. The sub-Group must coordinate their agency service delivery to schools and ECEs, to prevent schools and ECEs
becoming overloaded” (ibid). DHBs were advised they could also choose to establish
other groups, and some have specific Māori, Pacific and breastfeeding advisory groups.
DHB key informants reported they established these groups through a mixture of
identifying and building on pre-existing networks and, where there were gaps,
developing something new. They observed it could take time to find the right people at
the right level for each group. Other organisations had “the resource issue” of having to
find the personnel and time to attend meetings, particularly if they were a regional
organisation being called on to respond to more than one DHB. In addition to the
requirement to engage with partners formally in the stakeholder groups, a Project
Manager identified two other key ways of engaging, namely going one-to-one to
organisations you want to work with you on the strategy and “going to meetings of all
sorts…where you can infiltrate HEHA.”
People interviewed within DHBs all spoke about their co-ordination role and the
importance of collaboration. However one NGO key informant questioned the cost of
HEHA Project Managers and the value of what they are doing:
From what I can understand, a lot of DHBs before HEHA had informal co-ordinated
groups of people who worked in physical activity, in obesity…and they would meet
informally to co-ordinate themselves, and now we’ve got HEHA co-ordinators in
those positions who sometimes feed into these groups or want to create new
groups.”
However one DHB key informant believed that while some HEHA collaboration had
strengthened pre-existing work, new relationships had also developed both between
them and other stakeholders, and between stakeholders themselves as a result of
HEHA. One DHB key informant also commented that having HEHA Project Managers
within DHBs had given strategic direction and impetus to nutrition and physical activity
work.
46
A DHB key informant spoke of the difficulty of trying to get people already involved in
‘HEHA’ work on board with the new Strategy:
When I started in the role, there was already a group of people working in schools.
Then when I came along, there was a lot of misunderstanding and suspicion
around what I was going to do. Was I going to take work from them? Were they
going to be no longer needed?... We were put in the role…to run a sub-group, and
they were going, ‘Well hang on, who are you?’...To say actually, we’re not a threat,
we’re working together. There was quite a lot of silo protection, patch protection…
so that was difficult.
Their solution was to work on developing relationships with the others, and
emphasising everyone was making a contribution to the same end goal.
There was also some resentment from existing organisations struggling to work with
limited money. As noted nationally, HEHA could gain more credibility with potential
partners when there is funding available, and conversely, if a DHB cannot fund another
stakeholder, it is hard to tell them what to do. “You can [collaborate] at a relationship
level, but when it goes down to the next level, as to who’s going to put their money or their
cards on the table, that’s when it gets really tough.”
Overall, collaboration seemed to be easier for two types of DHBs:

DHBs with a strong, pre-existing population health focus that encompassed
nutrition and physical activity work which was able to be brought in under HEHA

Smaller DHBs with pre-existing working relationships with their community
partners, and for whom “collaboration is actually critical to our success and to our
continued existence. So we’re predisposed towards that in any case.”
However there were limits to the capacity for collaboration. Key informants in one
small DHB acknowledged a risk of overloading the small pool of people who were
already called on to represent their organisation on multiple groups. Informants also
considered it was easier to engage where there was a small number of regional groups
(e.g. one territorial authority or one PHO, rather than several of each).
DHB key informants appreciated where there was good collaboration at a national level
that fed down into district relationships too. For example, they reported that the
national partnerships around Mission-On supported local engagement between the
health and education sectors. In some cases, national direction was considered essential
before local engagement could take place. An example of this was given about working
with Kōhanga Reo: “regionally they get their directive from the national body, so we
aren’t actually in a position to work with them regionally until the national body gives the
ok.”
As with national level collaboration, DHB key informants note there can be challenges
working across sectors (such as between health and education) and time was needed to
develop relationships and understand different ways of working. In addition, “There’s
still quite a lot of people working in their silos”, which makes collaboration difficult. A
contributing factor to this is limited funding and the desire to protect that funding. In
47
contrast, a factor facilitating collaboration is finding a mutual focus that furthers the
aims of each participating organisation, while also encouraging synergistic HEHA
activity.
Most DHB key informants thought collaboration was developing (sometimes from a
slow start) and working as HEHA gained credibility: “Good partnerships have been
established - some including the DHB, others just between stakeholder organisations.”
However, this was not always the case. One informant said,
If we’re being perfectly honest, how’s it worked? – not very well, I’d say. There’s
been relationship issues that continue on. A big party in our area doesn’t agree
with an approach… I’ve found it quite a difficult environment, and relationships
have been strained. It’s been tough, trying to get alignment.
This informant thought that the difficulty was identified as being at a strategic level,
while “on the ground” people were willing to work together.
A positive aspect of collaboration among DHB HEHA teams is the development of some
regional groupings of project managers and district co-ordinators, meeting for peer
support, information sharing and co-ordination of work across districts. Regular
teleconferences between the project managers and the Ministry of Health HEHA team
were considered to enhance this collaboration.
Another set of health organisations which could be expected to play a role in HEHA, and
be an important collaborative partner for DHBs, are their Public Health Units (PHUs).
There are 12 Regional PHUs in New Zealand, each owned by and servicing one or more
DHB areas. However, PHUs are funded directly by the Ministry of Health. Their work
includes a nutrition and physical activity focus, which has been realigned within their
contracts to link with and support HEHA. ‘Fruit in Schools’ funding is also channelled
through PHUs. However the Ministry of Health decided to channel most HEHA funding
through DHBs’ Crown Funding Agreements, and establish the new project manager and
district co-ordinator roles in Planning and Funding arms of the DHBs. This was a
deliberate decision, to ensure HEHA is incorporated within the planning and funding of
every DHB, and is integrated across the whole continuum of health care from “primary
prevention right through to secondary care.”
Some DHB HEHA team members who were interviewed seemed to have developed
good working relationships with their PHU, but some reported there have been some
tensions about respective roles and activities. HEHA project managers saw aligning
their work with PHUs as part of their role:
Those [PHU] contracts include nutrition and physical activity, and state a link to
HEHA, but the alignment is not as clear, and I think that the role of co-ordination is
also co-ordinating some of those other positions, managing some of the other
funding that’s coming in from other places. It’s not HEHA directed, but aligning
that with the work that HEHA’s doing so it’s not either a conflict or an overlap.
The keys to collaborating together seem to be communication and developing
relationships: “We are getting there, but it’s taken all this time to get to everybody
understanding everybody’s role, what the expectations are, and then starting to work
together.”
48
Public Health Unit Views
All PHUs reported ways in which they are trying to collaborate with DHB HEHA teams,
including through being part of steering groups and education sub-groups; some
sharing and aligning of planning; information sharing; and working together on
particular projects. Communication and collaboration had taken time to develop, but
seemed to be improving. Collaboration was more difficult for those PHUs covering more
than one DHB, with the HEHA programmes in different DHBs sometimes having
different priorities and approaches, and with PHU representation being sought for
multiple meetings. One PHU key informant commented that their nutrition and physical
activity work had sometimes been made harder by HEHA, with having more ‘players’ to
work with. Another said there had been some duplication and confusion with both
themselves and the HEHA team working in the community, with sometimes a lack of
communication. “They’re confused about whose role it is to do what.” A further example
of confusion was a situation where schools were suddenly approached by DHB HEHA
team members independent of existing PHU work and relationships.
NGO Views
Among NGO key informants, there were varied views of how well the Ministry of Health
had engaged with their organisations around the Strategy, from “I have a reasonable
working relationship with them” to “I don’t think they have engaged with me at all.” There
was some acknowledgement from the Ministry of Health that engagement with NGOs
has been slow, but is being worked on. In one region, poor communication between a
DHB and an NGO had led to some duplication of activity (both running workshops
covering the same topic), with each suggesting the other should have informed them of
their planning. Opinions among NGO key informants also varied as to whether they or
the Ministry of Health should be working with the food industry. One person said,
“To me, it’s whatever works…but you have to be careful, because we’ve worked with
the tobacco industry before and we know the games that can be played by industry
and the powerful lobby that they have.”
However another considered,
I feel they [the Ministry of Health] want to keep the food industry happy. They have
two people employed with the Ministry of Health in Auckland whose sole job is to
co-ordinate with the food industry about reformulating their products. Well I
believe there’s too much emphasis on keeping the food industry sweet, not keeping
the community sweet.
Collaboration in summary
In summary, all key informants agreed on the importance of collaboration for the
success of the Strategy. They did not always find collaboration easy in practice, and
recognised that it needs time and trust to develop. Some key informants would like the
Ministry of Health to improve co-ordination across the Directorates that have a role in
HEHA. Informants considered that good collaboration has developed between the
49
Ministry of Health, the Ministry of Education and SPARC. They thought this was due, in
part, to the mandate from their Ministers to work together on Mission-On initiatives
(which also includes the Ministry of Youth Development), and because of the earlier
formal Tripartite Memorandum of Understanding, which has now ceased. Intergovernmental collaboration on HEHA beyond these agencies seemed less well
developed at this stage. Key informants identified a need to build stronger linkages
around shared issues in order to increase collaboration with other agencies.
Most DHB key informants reported good support from the Ministry of Health with
respect to HEHA implementation, but some stated they would like more flexibility in
how they can implement HEHA locally. DHBs were developing collaborative
relationships with local stakeholders, which was easier for smaller DHBs and those with
a stronger pre-existing population health focus. Good collaboration between agencies at
a national level was also reported to help facilitate local relationships. An NGO key
informant questioned the need for DHB HEHA project managers. Some existing
community groups and Public Health Units were also initially suspicious of the new
project manager role.
c. Engagement with priority groups
The HEHA Strategy and Implementation Plan identify four main priority groups: Māori,
Pacific peoples, children and families and lower socioeconomic groups (6). There was
agreement among key informants that these are the appropriate priority groups
because they have the greatest needs. In the case of children and young people,
informants considered they are a priority because of the possibility of positively
affecting eating and physical activity patterns early in life. A few informants thought
there were additional priority populations in their area: Asian people, refugees, people
with mental illness, and the elderly.
Consultation on the initial draft of the ‘Healthy Action – Healthy Eating’ Strategy
included three hui (attended by 35 Māori) and one fono (attended by 28 Pacific people),
and there were Māori and Pacific participants at the other five general meetings .(40)
Ministry of Health engagement with the priority groups has continued in a number of
ways. The HEHA project team currently includes a Māori advisor and an analyst
working on Pacific issues, and also consults with the Māori Health and Pacific Health
policy units. The Sector Steering Group has representatives from Te Puni Kōkiri and the
Ministry of Pacific Island Affairs and implementation has been guided by advice from
Māori and Pacific caucuses and a Youth advisory group. There are some links between
the Ministry of Health and national Māori and Pacific providers, and with Māori and
Pacific General Managers in DHBs. National campaigns such as that around
breastfeeding have targeted Māori and Pacific communities, and there are some Māori
and Pacific HEHA workforce initiatives. From the Ministry of Health perspective,
engagement with the priority groups was considered to be working, “but like anything
when you have a few people advising, it doesn’t cover everybody and there is always
somebody in the sector in the priority groups that feel that they haven’t had a chance to
input.” Another Ministry of Health informant commented there has been some criticism
50
from Māori about a lack of true partnership, and acknowledged there is some truth to
this. However partnership at a local level was viewed as most important, but “It’s really
difficult to be in partnership between the Ministry and local communities…and we do rely
on DHBs for that, and some DHBs are more successful than others.” The need for better
communication with Māori and Pacific peoples was also recognised, and there is
currently a focus on strengthening communication and its effectiveness from the HEHA
team to DHBs and communities.
The focus of Mission-On is children and young people aged 0 to 24 years old, including a
focus on the other target groups (Māori, Pacific and low socioeconomic status). A key
informant reflected back on the initial development of Mission-On which occurred with
urgency and “with no time for consultation.” However, a key informant reported the
programme has subsequently sought the advice and involvement of other government
Ministries, and of relevant stakeholders groups for particular initiatives. In addition,
…everything we’ve designed for young people has been done with children and
young people, their feedback, their advice and their guidance, their testing, and
particularly Māori and Pacifika young people. So everything we’ve designed, it’s
been tested with them; they’ve told us what they want.
Methods of engagement included using existing youth networks, focus groups, surveys
and feedback via websites. However the key informant acknowledged there has been
some criticism by Māori leaders that they have not been consulted about Mission-On “because they weren’t necessarily providing the young people, or supervising or running
that [consultation], it has not satisfied their desire for engagement.”
Some government key informants noted that it may be difficult for the Ministry of
Health to get other government departments to target the HEHA priority groups if they
do not have the same priorities. A Ministry key informant commented:
…you’re really dependent on the other agencies and they’ve got different target
populations…so we’re trying to work with them to encourage them to focus on
certain population groups, but their funding criteria and mechanisms for funding
are different. So in terms of reducing inequalities, that’s always been quite tricky.
Conversely, a key informant from another government agency noted,
This is a fundamental difference between… [us] and the Ministry of Health, is that
we do not focus on any inequalities…[while the Ministry of Health] come very much
from a tackling inequalities framework…it has been a sticking point in the
relationship.
The Ministry expects DHBs to engage with priority groups at a district level, which,
according to one Ministry key informant,“in some areas it’s going well and in others it’s
not.” DHB key informants reported identifying and engaging with local stakeholders
from the priority groups, including their participation in steering groups and in HEHA
initiatives. Some DHBs have established a Māori reference group specifically for HEHA;
others have piggy-backed onto an existing group: “Māori very clearly told us, ‘Don’t come
and create something new, we actually have a number of forums that we’d prefer you to
do the business through.’” There is also internal liaison between HEHA managers and
Māori health (and where appropriate, Pacific health) teams within the DHB.“Our HEHA
coordinator works with the Pacific team and the Pacific team go out and actually find the
51
initiatives that are going to work best with those communities. The same with Māori
really.”
In 2007, the government announced funding through HEHA for community obesity
prevention projects for Māori and Pacific (the latter in the seven DHBs with high Pacific
populations). The Ministry of Health then developed the HEHA Community Action
Project with Māori and Pacific stakeholder workshops having input into the
development of the service specifications (41). Within DHBs, Community Action
Projects are required by the Ministry of Health to be jointly accountable between the
HEHA Programme Managers and the Māori and Pacific General Managers – “Now the
whole idea of that is to make sure that they are working together…and that seems to work
some places but not everywhere and again it takes a long time to get that engagement.”
Some DHBs have a specific Māori HEHA co-ordinator. One DHB key informant
commented, “Certainly the community projects that we’ve been involved in, …[it’s] being
very clear about having that process located within Māori ways of doing things.” This
person had also provided support to groups around how to complete their application
for Community Action Project funding, and workshops about reporting requirements
“so the groups were very clear and also felt confident in what they were doing.” In
contrast, another DHB key informant commented some Māori had not wanted to engage
“because they didn’t feel it reflected the way that they worked.” A third DHB key
informant commented,
I think the particular success for our area has been the Māori part. There’s
absolutely no doubt in my mind that if you approach and seek engagement from
groups such as Māori groups or Pacific groups, then the most effective mechanisms
are by Pacific, for Pacific, by Māori, for Māori.
Some DHB key informants commented on mixed messages about the true priority of
Māori, for example with the lack of resources in Te Reo (and Pacific languages) and
their perceived lower quality.
In many cases, the resources come out in English and two years later it might come
out in Māori, and automatically that makes Māori feel they’re [far] back on the
agenda, and they’re supposed to be a priority group. I think that’s something that
needs to be at the forefront of Education and Health’s minds when they’re
publishing resources.
It was commented that translated resources alone are not the answer either; culturally
appropriate resources are also required.
Another example of mixed messages was a post hoc attempt at ‘engagement’:
I remember going to a hui the Health Sponsorship Council ran around Feeding our
Futures1 and it had been launched in May at the ANA conference, and they came in
in June and said, ‘Right, Feeding our Futures, how do you think we should be doing
1
Feeding our Futures was a healthy-eating social marketing campaign launched in May 2007, targeting parents and
caregivers of children aged 8 to 12 years old. It was run by the Health Sponsorship Council in partnership with Agencies for
Nutrition Action.
52
this for Māori?” And they [Māori participants] said, “Well, you’ve already decided.
Why are you talking to us?” It was already on TV. That was quite offensive.
For most key informants, the priority focus on children, young people and their whānau
is expressed through HEHA work in schools, including Mission-On initiatives, Fruit in
Schools and Nutrition Fund activities. DHB key informants noted the criteria for these
also target low decile areas, and high Māori and Pacific populations.
Direct engagement with lower socio-economic groups seems less strong than with the
other priority populations. There is some engagement with the Ministry of Social
Development both at a national level and by some DHBs at a regional level. Some see
overlap between lower socio-economic groups and Māori and Pacific groups. The most
common reference to targeting for lower socio-economic groups is the focus of
educational initiatives on lower decile schools, both through Fruit in Schools and
direction to DHBs that Nutrition Fund application criteria should include high need
groups.
Key informants at both national and DHB level identified some risk around engagement
with priority groups if there is not sufficient funding to then meet the aspirations
identified.
d. MAPs/Planning Processes
DHBs have been required to conduct a needs assessment of district HEHA needs and
construct a plan to meet these needs. The resulting Ministry Approved Plans, or MAPs,
were submitted to the Ministry of Health for approval. MAPs were produced for the
2007/08 and 2008/09 years, but a third MAP is not going to be required.
Ministry of Health key informants saw the MAPs as being primarily for the use of the
DHBs themselves, as a starting point for them taking responsibility for the HEHA needs
of their region and developing local solutions to those. The MAPs were intended to line
up with the DHB District Annual Plan (DAP), providing more detail on HEHA, without
duplicating material. DHBs report quarterly against their MAP.
The Minister of Health’s annual “Letter of Expectations” to DHBs sets out the Minister’s
priorities for their DAPs. These letters were reviewed from the 2003/04 year, until the
2009/10 year. HEHA is first mentioned in 2005/06, as an implementation priority, to be
done through collaboration within the sector and intersectorally. In 2006/07, it noted
that progress on the implementation of HEHA was just beginning, and “another year’s
assertive progress in implementing the Healthy Eating Healthy Action Strategic
Framework” was part of getting “‘ahead of the curve’ on the chronic disease burden.”
Priorities in the 2007/08 year were to be the same as the previous year, including the
emphasis on chronic disease, but it was noted that “The Healthy Eating Healthy Action
Strategy and Cancer Control Strategy are now gaining momentum”, but need further
and faster implementation. This message was repeated in the 2008/09 letter. The
53
2009/10 letter, the first by Tony Ryall as Minister of Health in the new National-led
government, does not specifically mention HEHA at all.
DHB key informants reported undertaking wide consultation with their stakeholders
and communities, as well as using existing DHB health needs assessment data, and
other available data (such as Plunket breastfeeding statistics). However, one DHB key
informant commented,
We got quite a directive thing from the Ministry. There is a clear Strategy and a
clear Implementation Plan, so why would we go out too much to determine what
the needs are? I actually think the national level data has given us a clear
indication…and the ability to get the local level data for us isn’t there.”
One DHB key informant noted community consultation was “both useful and
problematic” – useful in terms of identifying “what the major issues and barriers in
healthy eating and healthy activity were”, but problematic in producing “a very broad
wish list of what the HEHA strategy would actually achieve” which did not match well
with the constraints of the available funding. The very targeted funding streams were
also reported by other DHB key informants to determine priorities for action.
HEHA work is not all new. In some DHBs, existing programmes were able to be brought
in under this umbrella. In addition, a DHB key informant commented on the importance
of acknowledging what was already being done in the community in order to get
stakeholders on board with the new HEHA framework, and as a basis on which to build
and extend action.
The MAPs had to be produced according to a prescribed Ministry of Health template.
For some DHBs, this was helpful with a new project and new roles to have direction
about what needed to be done. However, for others, the process was “tedious” and
perceived to be “about really meeting the Ministry’s need.” There was criticism by DHB
key informants of the time it took to produce the plans against a tight timetable, and
that the process duplicated work that had to be done to produce the DHB DAP, but with
different timing. The resulting documents were also described as being lengthy and
difficult to read. In addition, two plans had to be produced within a short time of one
another: “It’s like you’re spending a lot of time reviewing something you only started a
year ago – no, give us three years and then let’s see how it’s going.” Some DHBs have
produced their own HEHA Strategic Plans, which then had to be fitted to the MAP
template. Reporting against the MAP was reported by DHB key informants to be
“bureaucratic.”
The MAPs are reflected in the current year’s DAP and it seemed this was what DHBs
were working off more. DHBs were pleased they were not going to be required to
produce another MAP, but would simply continue to incorporate this planning into the
DAP. One key informant did note, however, that because HEHA is a broad population
strategy, it is not always easy “to actually integrate it into particular parts of your service
delivery model.”
PHUs have their own planning processes which informants said were separate to the
DHB HEHA teams and not always well-aligned with them. However, there was some
54
communication between PHUs and DHBs to identify areas in which they could work
jointly to assist one another and avoid duplication, or conversely, work in different
areas to increase the overall coverage. One person explained how their PHU work could
be included in the DHB MAP, although it is not DHB-funded, nor accountable to the DHB,
which had created some issues in terms of other people’s understanding of their
responsibilities and expectations of things such as being able to request that a report be
written. Most PHU key informants said that their planning was linked with the HEHA
implementation plan, but one commented that did not have a role in their planning.
Analysis of MAP1 and MAP2 Plans
The MAP1 and MAP2 plans for all 21 DHBs were analysed against their Ministry
templates. In addition, they were analysed against the criteria of the Australian
National Audit Office guide for the implementation of programme and policy initiatives
Ministry of Health communication and feedback about the MAPs was also reviewed. In
MAP1, the main DHB HEHA steering group usually included individuals with senior
roles from within their respective organisations, for example, team leaders, project
leaders, managers, CEOs and Mayors. Sub-group membership contained individuals
with senior roles as well as physicians, school teachers, and other non-leader and nonmanagerial individuals. Use of external policy documents and supporting frameworks
(i.e., National HEHA Communications Strategy) was evident in the MAPS. Māori and
Pacific people as a priority population were frequently referred to, although some DHBs
had considerably more detailed information on priority groups than other DHBs. In the
final section of the MAP1 template, DHBs were asked to comment on lessons learnt what had and had not worked with regard to their HEHA initiatives, and what they
would do differently given the chance. The aim of this process was “to promote and
foster an information sharing and learning environment between the DHB and the
Ministry of Health”, and act as a learning resource for other DHBs ,(39, p39) Eleven of
the twenty-one DHBs provided feedback within this section. The main issue identified
was communication and collaboration difficulties. Other themes included feasibility,
lack of resources, mandating priority, having realistic timeframes, and availability of
effective evaluation methods.
In MAP2, DHBs often provided more detailed Terms of Reference for steering groups
and subgroups than was required by the Ministry of Health. A common inclusion was
“conflict of interest” clauses for when group members approve funding to organisations
they represent. A less common clause within the Terms of Reference was the use of a
“conflict of management clause” to help resolve conflict if it arises between group
members. In at least one Terms of Reference, members who were not directly employed
by the DHB were reimbursed for their time.
The Ministry of Health expected that group membership and the group effectiveness
would be assessed periodically. Some DHBs did alter their governance structures.
Examples of changes include:

Increasing the number of subgroups as a new need was identified.
55

Disbanding and reorganising subgroups that were less effective than what
was desired.

Combining subgroups to reduce duplication of effort.

Decreasing the number of individuals within a subgroup to make the group
more effective and workable.

Allowing subgroups more time to deliberate with the steering group
regarding the implementation of the HEHA strategy.

Attempting to include more Māori and Pacific representation within the
subgroups.
The wide variety of group changes illustrates how DHBs tailored their governance
structure to meet the need of their region.
The MAP2 template retained a strong emphasis on Māori and Pacific communities,
which was consequently reflected in the DHBs’ MAPs. Breastfeeding, schools and early
childhood education centers, community action and workforce capacity and capability
(specificially Māori and Pacific where appropriate) were identified by the Ministry of
Health as priority areas for DHBs to target in the second MAP. In addition, DHBs were to
choose at least two further priorities from a list of nine options (primary and secondary
health care settings; lower socio-economic groups; children, young persons and their
whānau; environments; social marketing strategies; working with industry; public
policy; monitoring, research and evaluation; and communications) .(42, p14)
In MAP2, DHBs were required to report against each initiative they developed and
update their stocktake and needs analysis. As the MAPs developed, the Ministry of
Health acknowledged that developing relationships with communities can take time.
The Ministry of Health adapted their expectations of DHBs’ progress and reviewed each
DHB progress independently (i.e. it did not compare progress between two DHBs as a
performance measure).
e. Implementation Activities
Key informants were asked about the activities being implemented under the Strategy’s
six approaches for action (build healthy public policy; create supportive environments;
strengthen community action; develop personal skills; reorientate services and
programmes; and monitor, research and evaluate(6)). The Stocktake of HEHA initiatives
provides data on Ottawa Charter outcomes focus of all initiatives(see Table 21: Number
of initiatives by outcome (Ottawa Charter) in Section 3: Stocktake of HEHA Initiatives)
showing the strongest focus has been on creating supportive environments. In
interviews, key informants were asked about the Ottawa Charter approaches they were
implementing and which they considered most important. The material in this section
includes the examples they gave, without being comprehensive of all HEHA initiatives.
Key informants all six of the approaches for action to be important parts of the multifaceted way in which HEHA needed to be implemented, and key informants were able to
identify activities that contributed to each of the approaches. However one government
informant commented that while their organisation was contributing to all the
56
approaches and they express a high level direction for HEHA work, “on the ground,
people get on and do business as usual and I don’t think people consciously…think about
whether they’re checking those boxes.”
‘Building healthy public policy’ included developing healthy policy within key
informants’ own workplaces (in some cases supported by the government ‘Walk the
Talk’ programme which is part of Mission-On) and workplaces generally (in conjunction
with Public Health); linking with local councils to promote ‘Active Communities’
strategies which aim to reduce barriers at the community level to participation in sport
and physical recreation (43); and including the expectation in contracts with
community organisations that they will review the food they provide and promote
physical activity. For NGO key informants, the most important part of their contribution
to HEHA is advocating for public policy which will create supportive environments for
healthy eating and healthy action, and make these the easy choices for people.
The most progress with ‘creating supportive environments’ was seen by all groupings of
key informants to be happening within schools and early childhood settings. They
considered important drivers for change in these settings were components of MissionOn Initiative 1, including the National Administrative Guideline2 and the food and
beverage classification system3. Mission-On has run campaigns to encourage children to
reduce their screen time and engage in more physical activities. Work by the Ministry of
Health with the food industry and broadcasters, also under the umbrella of Mission-On,
has led to some voluntary agreements about controlling advertising to children.
‘Strengthening community action’ is the focus of the Māori and Pacific community
action projects (see above). Key informants considered it is also important that
activities in schools under the Nutrition Fund4 are driven by schools and families, and
one DHB key informant commented they were beginning to see the potential for these
projects to have an impact beyond the school to the whole community. Strengthening
community action was considered to be less apparent in Mission-On, although Initiative
2, student-led health promotion, includes something of this approach.
‘Developing personal skills’ was noted to often be easier to focus on than working to
change policy and the environment. For example, a DHB key informant commented that
while supportive environments are probably the main focus they want to see, this often
The Ministry of Education National Administrative Guideline 5 requires school Boards of Trustees ‘to provide a safe
physical and emotional environment for students.’ From June 2008, two additional clauses were added, requiring Boards to
‘promote healthy food and nutrition for all students’ and ‘where food and beverages are sold on school premises, make only
healthy options available.’ The second of these clauses was removed in February 2009, during the course of these key
informant interviews. (see
http://www.minedu.govt.nz/educationSectors/Schools/PolicyAndStrategy/PlanningReportingRelevantLegislationNEGSAnd
NAGS/TheNationalAdministrationGuidelinesNAGs.aspx)
3 The Food and Beverage Classification System identifies foods and beverages in three categories: not recommended for
provision by schools or early childhood education services during the school day; for limited provision only; or appropriate
for every day consumption and to be promoted. (See http://www.everyday-sometimes.org.nz/)
4 As part of the Mission-On initiative to improve nutrition within schools and early childhood education environments, a
regional nutrition fund.was available to support the implementation of nutrition guidelines in these settings. Subsequent to
this round of key informant interviews, the Mission-On programme has been discontinued. Nutrition Fund funding is to be
rolled into a combined Community Action Initiative and Nutrition Fund.
2
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turned into developing personal skills at the delivery level. Therefore there could be a
difference between what they hoped to achieve and how that was translated in practice.
In another DHB, a stocktake had been done of existing projects, and it noted many had a
personal skills focus, so “That tells us that as we move forward with our Māori and Pacific
plans, for example, that we need to make sure there is quite a community action
component to it”. An NGO key informant expressed concern that this approach to action
has in fact been the focus of HEHA activity, but they had no faith in the ability of this
approach to change people’s behaviour, emphasising instead their belief in the need for
environmental levers to bring about change. HEHA activities which do promote the
development of personal skills include the provision of information to individuals,
groups and the general population (both directly and through communications
strategies and social marketing campaigns); Mission-On and other work in education
settings to inform and up-skill children, hopefully embedding healthy behaviours early
on; and workforce development initiatives.
The ‘re-orientation of services and programmes’ had been an initial focus of HEHA
before new funding became available, including realigning Public Health contracts with
HEHA. Re-orientation of services and programmes was acknowledged to have some
difficulties without funding and accountability leverage, and work to re-orientate
personal health services to incorporate a public health focus on nutrition and physical
activity was perceived to be slower than other approaches to action under the Strategy.
Some key informants again pointed to aspects of work in schools fitting under this
approach, such as the National Administrative Guideline leading to changes in school
canteens, and the reorientation of contracts for a student wellbeing programme to link
it with the HEHA strategy.
Finally, ‘monitoring, research and evaluation’ have been important foci for the Ministry
of Health as they seek to develop the New Zealand evidence base, including national
evaluations (such as that of Fruit in Schools and the overall evaluation of the Strategy
being carried out by this research), and local evaluations through the DHB evaluation
fund. Evaluation was also a strong component of Mission-On.
One key informant suggested ‘sustainability’ should be added as a seventh approach for
action, and some other DHB key informants commented that they are working to ensure
the work they establish with community groups in particular will be self-sustaining in
the future, especially as on-going funding is uncertain. One DHB was using what they
termed “catalyst phase funding” whereby the DHB part-funded a programme and
worked with the organisation “to help you build that sustainability.”
While key informants recognised all the approaches for action are important and
necessary, when asked which are most important, the emphasis was on building healthy
public policy and creating supportive environments because these were seen to be a
necessary precursor to achieving individual and community behaviour change.
Strengthening community action was also a key for some: “…engaging the community so
they do it for themselves or at least they say what works best in their community is crucial
so it’s not a top-down thing.”
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There was a noticeable difference of opinion between the perceptions of the Ministry of
Health and NGO key informants around which approaches for action are or should be
focused on. Ministry of Health key informants considered they had had “a particular
focus on changing the environment to make healthy choices easier for people”, pointing to
this being one of the key population health messages of the Strategy, and “what’s
probably not as overt is developing personal skills.” On the other hand, some NGO key
informants considered there was too much attention on education and personal change,
and healthy public policy and environmental change were not a strong enough priority
of the Ministry. Some NGO key informants would like greater regulation of such things
as what food can be sold in schools and workplaces, and on food marketing (particularly
on television). Some thought the Ministry should be driving this, but others recognised
the Ministry is constrained by government policy and direction, and that NGOs have an
important advocacy role in this area.
In terms of the overall focus of HEHA implementation activities, the view of Ministry of
Health key informants was that nutrition has received greater attention than physical
activity to date, because there was less happening on nutrition at the time the Strategy
was developed. However they expected that this is likely to be balanced up with more
focus on physical activity again in the next phase of the Strategy. Key informants from
two other government agencies also considered the emphasis to date had been on
nutrition. DHBs’ focus is in part constrained by funding directives (for example, the
nutrition fund directs the focus of work in schools). However two DHB key informants
and one from within a government agency also commented on the importance of
holding nutrition and physical activity together, rather than viewing them as separate
entities.
Key informants’ perception of a greater emphasis on nutritional activities differs from
the findings of the stocktake of HEHA initiatives and value-for-money analyses (see
sections 3 and 6) which suggests there may be a greater number and more spending on
physical activity initiatives. This difference may be due to incomplete data, particularly
funding information, but highlights a need, as the evaluation proceeds, for further
investigation of the balance of programmes.
PHUs were asked about how HEHA had affected the work they were doing on nutrition
and physical activity prior to the implementation of the Strategy. Several considered
HEHA had given strategic direction to nutrition and physical activity work and a
stronger mandate for what PHUs were doing in this area. Some said their work had
been re-aligned to HEHA, and HEHA had brought new work through Fruit in Schools,
and access to other resources associated with Feeding Our Futures, and Mission-On.
One person felt that “the nutrition fund has been a really key tool for us to engage with
some of the schools that are a bit harder to engage with.”
One PHU key informant considered that HEHA had generated more networks and
opportunities to share best practice, but another rued the loss of a central meeting of
health promoters which had “fizzled out”, with the Ministry of Health instead supporting
networking by HEHA project managers.
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As noted earlier, in some cases, having another programme of nutrition and physical
activity work driven out of DHBs has sometimes created confusion and “has made things
a little more disorganised from our perspective.” A key informant in one PHU considered
HEHA had raised the profile of breastfeeding and their PHU had initiated new work in
that area, but for a participant in another PHU, “With the implementation of HEHA and
the establishment of the steering groups, having to go through those processes has stalled
the work we were doing with breastfeeding promotion.”
f. Alignment of HEHA implementation with the Implementation Plan
All key informants were asked to what extent they thought the implementation of HEHA
had aligned with the HEHA Implementation Plan .(8)
The Ministry of Health have linked their work programme to the Implementation Plan,
and believe alignment has been “very close”, with 75 out of the 87 actions reported to be
underway by the end of 2008 .(9) Informants from other government departments had
varying levels of recognition and use of the Implementation Plan, from having
contributed to it and seeing their work relating well to it, to someone who said, “No, I
don’t think so [that the plan has been used].” For government agencies, one key
informant commented it is something of a “chicken and egg” situation – “I mean, our
initiatives are in the Plan because we were already doing them, so the implementation is
aligned…and I think there’s a few other agencies that are like that.” An informant
involved with Mission-On considered all those initiatives would fit within the HEHA
Implementation Plan, but the key direction for this work “is its original Cabinet paper
and any other instructions that have come from Cabinet since.” This reflects the fact
Mission-On is a campaign contributing to the implementation of HEHA rather than
being a direct action within the HEHA Implementation Plan.
An NGO key informant remarked, “I know it exists, but it doesn’t have a lot of relevancy to
what we do.” Another key informant considered things had been delivered according to
the plan, but was critical of what is or is not in the plan, commenting again on a
perceived lack of emphasis on environmental change rather than a focus on individual
behaviour modification.
Within DHBs, there seems to be variable use of the plan, from “Very closely aligned as
the basis of the HEHA implementation plan is the basis for our [DHB] plan” , to another
where a key informant said,
End of the day, they’ve set out this is what needs to be done. How you do it is up to
you. Personally that’s how I see it. As long as we are contributing towards what
they set out, and I think [our] HEHA is, it’s doing very well.
DHBs were following their own HEHA programme plans (within MAPs and DAPs), and
with 87 actions within the Implementation Plan, there was a view that almost anything
would fit into the plan somewhere.
A Ministry of Health key informant considered some things happening in DHBs are not
totally aligned with the plan, but are still broadly in line with it, and have arisen as
60
responses to locally identified needs and opportunities. One DHB key informant
commented that there were too many actions to initiate work on them all initially, and
they had grouped them into four areas and converted them to reflect the work of local
organisations in order to make them more user-friendly. Another DHB had brought
other health promotion plans together with HEHA, and restructured their governance
groups into one group covering all the initiatives.
Key informants reported there has been mixed capacity and capability to deliver HEHA
throughout the sectors, and this has had some effect on the speed of implementation.
The Ministry of Health considered that at the time implementation began, there was not
the infrastructure and capacity to deliver within DHBs, hence the decision to establish
and fund project manager and district co-ordinator positions in DHBs and have them
develop intersectoral groups to partner with. DHB key informants agreed they probably
could not have managed to deliver or spend on HEHA more quickly than they had
initially, pointing out they needed time to develop new ways of working and establish
programmes. A benefit of collaboration may be the ability to tap into the capacity of
other organisations too, as one DHB key informant commented, “…we within our DHB
have quite minimal capacity I think to actually support HEHA so we do rely on other
organisations.” One DHB key informant saw HEHA as having increased the overall DHB
capability around public/population health; on the other hand, another already had a
strong commitment to population health initiatives, and saw HEHA as a funding vehicle
and mechanism to support that existing work. One person commented positively on the
learning and workforce development that had come through HEHA, including in
developing, monitoring and evaluating programmes, although another person noted the
weakness of some programmes and the ‘catch 22’ that they are weak “because there
wasn’t enough capacity there, and yet if they don’t get funded, they can’t build the
capacity.”
The HEHA Strategy identifies having a skilled and knowledgeable workforce in place is a
priority for achieving the goals of the Strategy, and one of the objectives is to support
workforce development .(44) The Implementation Plan includes a specific action to
“develop and implement a strategy to increase capacity and capability of trained Māori
and Pacific helth professionals and community health workers” .(8) Key informants
commented on Māori and Pacific workforce shortages in the nutrition and physical
activity area. They also noted a shortage of lactation consultants (the Ministry of Health
is in the process of establishing a training programme to address this); a lack of
dieticians in hospital services and especially community dieticians; and the general lack
of a dedicated nutrition and physical activity workforce, with this generally being a part
of broader health promotion work, which one person saw as being poorly paid and
having a high staff turnover. Growing capacity in regional sport and recreation
programmes was another identified need, along with building capability within
communities so they themselves can lead HEHA activity.
NGOs were acknowledged by one Ministry of Health key informant to have a lot of
capability “because they’ve been strong advocates for a long time for their particular set of
issues.” However one NGO key informant noted they do not have a lot of additional
capacity or resources to put into HEHA, but they would continue to contribute where
61
able. A DHB key informant commented on a difficulty in trying to partner with
community organisations:
That’s been an interesting journey because as much as you want to have them on
board, a lot of them just don’t have the extra body or resource available to actually
support what you’re trying to achieve…and when we’re not offering any money, this
sometimes can be an issue for those organisations.
One NGO key informant was concerned there had been pressure from the government
to produce quick “runs on the board” within unrealistic timeframes and without
immediate capacity to manage new resources, and that this had also resulted in
decisions not based on best practice.
g. Learning Environment
The Ministry of Health has sought to encourage the continual sharing of new learning
about HEHA among stakeholders. It has developed a number of fora for doing this,
including e-mail updates, a bimonthly newsletter, and the on-line HEHA Knowledge
Library (where research can be found and shared) and HEHA Toolbox (a website with
evaluation tools for DHBs to use). The HEHA Network website is in the process of
development and will allow information sharing, networking and coordination.
In 2007, the Ministry of Health funded a provider to run workshops and professional
development for people working on HEHA. A DHB evaluation fund has been established
to help build evidence of what works in the New Zealand context, and its initiation was
accompanied by evaluation training workshops throughout the country. In 2008, the
Ministry ran a research and evaluation conference to disseminate the work that has
been done under HEHA. Agencies for Nutrition Action has been funded to run a
conference in alternate years, as well as regional fora and hui and fono (sub-contracted
to Te Hotu Manawa Māori and the Pacific Island Food and Nutrition Action Group).
These activities were reported to have had a high level of participation.
The Ministry has also encouraged and supported regional and national networking of
HEHA project managers and district coordinators, through regular teleconferencing and
in-person meetings. These provide peer support and encourage collaboration and
learning. The Ministry is also developing an orientation/induction package to assist new
project managers to get up to speed quickly.
While the Ministry had clearly put a lot of effort into trying to communicate well, there
was also recognition “different ways of communicating probably need to be found”, and
that while communication was reaching the “working level” well, it was not always
reaching the attention of more senior levels within organisations which have the power
to give greater emphasis to HEHA: “there is a need for us to really look at how much
Senior attention is applied to HEHA”.
Generally DHB key informants were aware of and appreciated the information available
from the Ministry of Health and thought they could feed back their own learnings. The
‘QuickPlace’ online forum to share questions and information had been helpful, but
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there had been problems accessing it recently, reported to be due to information
technology difficulties at the Ministry. Agencies for Nutrition Action and Fight the
Obesity Epidemic were also mentioned as useful sources of information for DHB HEHA
teams.
DHB HEHA members share information amongst their teams and local stakeholders and
through networking with other HEHA workers, although one person commented, “…the
sharing of information across districts….happens to some degree but…I think that could be
enhanced considerably.” Sharing experiences and resources was considered important,
not only to foster learning, but also to avoid duplication of effort. A DHB key informant
commented on the need to share information with communities too – “…it’s not just
about the co-ordinators knowing, it is about sharing that [information] with the
communities so communities can see what is working in other areas and see if they can
replicate that”, and another reflected that within their DHB, “we try and create a real
learning environment, but I don’t think we are doing it so well back out to the community.”
Some DHB key informants reported using feedback from evaluations to improve their
programmes (but not all have evaluations completed yet). It was considered important
that there be continued use of evidence to inform the Strategy going forward. There is
also a need for evidence about long-term effects of activities; some have evidence of
short-term effectiveness, but whether this is sustained is as yet unknown.
Mission-On partners spoke about the development of those collaborative relationships
as a learning process, and of on-going evaluation of programmes and their resultant
modification as required. Another government department key informant spoke of
sharing their research with the Ministry of Health and that this was well-received by the
Ministry. They also appreciated receiving information such as the HEHA newsletter, and
in turn shared some of this with their own networks. However another government
department key informant felt overloaded by a barrage of electronic information not
well targeted to their area of work. There was mixed appreciation and criticism from
NGO key informants too, with comment that the HEHA newsletter could be a “tad
glossy” and perhaps also focused on success stories rather than a “warts and all
approach” including learning from things that were not so successful. A Ministry of
Health key informant also recognised the need to learn from failure as well as success,
and reflected, “…sometimes we’re too hard [on failure] and the perception is we have
wasted public money if it didn’t have the desired outcome.” One NGO key informant
considered the Ministry did not recognise the breadth of what they had to contribute,
and was also critical of the decision to have a new HEHA newsletter from the Ministry
when the Ministry was already funding a newsletter being produced by an NGO. This
duplication was viewed as a waste of money and source of confusion within the sector.
However, the purpose of the newsletters may differ.
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2. Outcomes
Key informants were aware of the goals of the HEHA Strategy (improving nutrition,
increasing physical activity and reducing obesity). Other goals mentioned were
“improved life expectancy and well-being” and “the downstream effect on cancer, diabetes,
cardiovascular disease and chronic disease generally, but obviously you won’t see that
coming through for a number of years.”
Only a small number of changes from the implementation of the Strategy have been
identified by key informants to date. The most commonly mentioned was a sense of
increased societal awareness about the problem of obesity and the need for good
nutrition and exercise. An example is media coverage, including general television
shows – “If you look at the stuff that goes on TV about ‘Down-size Me’ or whatever the
programmes are, it’s become part of popular public discourse that obesity’s a problem and
we need to do something about it.” HEHA social marketing campaigns are also
considered to have raised public awareness, with evidence of high population
knowledge of the messages of Push Play and Mission-On campaigns. One key informant
said, “I think it is the awareness that’s creating attitude change, and gradually that’s
filtering out.” Examples were given of individual and collective change, including the
food being eaten in key informants’ own workplaces, at marae gatherings and at Pacific
church functions. One DHB HEHA team said a number of workplaces were contacting
them regarding changing their workplace catering to healthier suppliers and options.
Another sign of change was less community resistance to being advised about healthy
eating and action: “When Healthy Futures and some of those programmes started, there
was the comment about the ‘food police’ and those sorts of things, and you just don’t hear
them anymore.” One key informant also commented that it is encouraging to see not
only growing individual awareness, but communities taking collective responsibility to
actually make changes, not just in eating, but, for example, in collective lobbying of a
Council to make environmental changes that support HEHA objectives.
As well as increased individual and community awareness about the issues, one key
informant also identified a change at Government level:
I think there’s been a shift, a sea-change at government level. That’s why the Select
Committee Inquiry was so important, because it was across a whole range of
Ministers, so I think at government level this is seen as critical…this country is not
sitting on its hands waiting to see what other countries will do; we are acting on it.
A second outcome of HEHA that was frequently commented on was changes in the
school and early childhood environments, including increased awareness about
nutrition and physical activity; nutrition and physical activity becoming “a way of life at
schools” rather than an ‘add-on’; changes in the food available in school canteens; and
gardening projects. This was attributed to Fruit in Schools, Mission-On programmes, the
Nutrition Fund and the work of HEHA district coordinators and others (‘Enviroschools’
64
also having an influence on gardening). The National Administrative Guideline (NAG) 5
was considered to have been an important lever for change in the education setting, and
key informants interviewed after its removal on 5 February, 2009 expressed concern
about the effect this would have. Two clauses were added to the NAG in May 2007
requiring Boards of Trustees to “promote healthy food and nutrition for all students;
and where food and beverages are sold on school premises, make only healthy options
available” (45). The second of these new clauses (NAG5 iii) has now been removed.
Some key informants were hopeful (but not certain) changes are sufficiently embedded
in some schools at least so that they will continue, but others felt it will be “…easier for
them to revert back if the messaging isn’t consistent, and those that are avoiding [change]
or are reliant on canteens to make money or are using not so appropriate fundraising
mechanisms, they’ll continue to do that.” Another key informant commented,
“Anecdotally, the principals have said they are on board”, but her children had then come
home “with a newsletter saying hamburgers and sausage rolls are now back on the menu.”
One PHU key informant believed the original NAG had also been starting to influence
change in the food industry as they looked at making changes to products for the school
market, and feared this impetus would now be lost.
Three PHU key informants spoke positively about changes through Fruit in Schools:
“Anecdotally, the people involved in delivering these contracts have seen improvements
with children” such as better concentration and (in another project providing fruit to
children) less dental caries. However, one added, “I’m not sure how sustainable those
improvements will be down the track once the contracts end.”
Another identified outcome was more consistent messages about good nutrition and
physical activity, “because when HEHA started, there was mixed messages about what
levels of activity you should be doing and what you should be eating, and I think we’re
starting to see a bit more consistency in that area.” More linkage of both physical activity
and nutrition, rather than a past emphasis “just on the eating side of it” was also noted.
In discussing collaboration, greater co-ordination of HEHA-related activities at all levels
and the sharing of resources were seen as other outcomes, along with growing
understanding that HEHA “is not just Ministry of Health stuff” but involves many other
sectors. Embedding collaboration was seen as important so that if a particular HEHA
position or funding ceases, the collaboration will continue. Capacity and capability
building and developing the necessary infrastructure associated with the Strategy are
also mentioned as outcomes.
Other changes noted were a perceived boom in community and individual gardening,
greater support around breastfeeding, and changes in commercial food activity:
I’ve seen some examples of community initiatives, where community retailers have
banded together to provide healthier food…Even some big chains like McDonalds
and so on, changing the fat in the oil, which wasn’t a direct HEHA Strategy
outcome, but I’m sure it’s the whole push has helped put those things in place.
An area where outcomes were perceived by some people to be slow was in
environmental change: “I think that is the weak link, but also there is more awareness
65
now of the environment…but it is obviously harder and slower to change the environment
than to develop a new programme or something like that.”
A final interesting area relating to outcomes is where HEHA has enabled synergies to
develop between organisations and programmes, or been a catalyst for the
development of other initiatives. Examples given included the Fruit in Schools
programme, which has been implemented as part of a wider health-promoting schools
programme that seeks to build an overall healthy lifestyle. HEHA was considered to
have been important in one area for the development of a regional cycling strategy
(work on this having preceded HEHA, but with HEHA being a “catalyst” for progressing
it). Gardening projects have spawned a number of linkages – in schools, with
environmental issues (particularly through ‘Enviroschools’); some marae-based
gardening projects not only teach gardening skills and also how to use the food, but
have then incorporated health assessments and set up a gym programme; a gardening
project at a women’s refuge had encouraged communication and participation together
from mothers and children, built self-esteem, and developed other skills like learning
how to seek sponsorship; and community garden projects were considered to be
building social cohesion.
HEHA fits well with other health promotion/healthy lifestyle activities. For example,
people taking part in community sporting activities were being encouraged to also eat
healthily, and to give up smoking; in one area, HEHA had joined population health and
renal services to contribute to ‘Just Water Week’; in another, there was support for a
campaign by PHOs to increase the number of Māori and Pacific women coming in for
breast and smoking screening, by linking in the importance of nutrition to cancer
prevention; and another DHB had provided fruit sponsorship at a ‘Bikewise’ event. One
person noted evidence physical activity improves mild to moderate mental health
conditions like depression, which is another opportunity for synergies.
In terms of outcomes specifically for Māori and Pacific peoples, there was again a sense
of heightened awareness about HEHA issues, and there were stories of changes in food
being served at marae and Pacific events, and of increased physical activity being
undertaken. The Māori Community Action Plan funding is being used to target this
priority group, and “We anticipate getting some good outcomes through that, but we
don’t yet have any evidence to prove or support that.” Another DHB key informant said,
“We’ve certainly focused on the target groups…but whether or not we’ve really or not
effectively reached target groups, I don’t think we know.” An NGO key informant
considered raising awareness about HEHA messages among Māori and Pacific groups
has probably been successful, but was concerned that if HEHA focused on individual
education and change, “it seriously runs the risk of increasing inequalities”, and urged a
stronger environmental change focus.
Asked about how they know HEHA is producing change, a number of people pointed to
the positive 2006/07New Zealand Health Survey findings that the increasing prevalence
of obesity among adults has slowed, and levelled out for children, and there were no
significant change in the rate of obesity for Māori men and women since 1997.(2) DHB
has conducted its own regional survey of children’s eating and drinking, and another of
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physical activity to gain baseline data, which can be compared for changes when
repeated in three to five years time. It will also give them an indication of how well the
generalisations from national survey data apply to them. A second DHB had had a
baseline health survey done of their population, which would again be repeated in three
years to assess changes.
Each Mission-On initiative has its own monitoring and evaluation plan, and SPARC
monitors its other programmes such as ‘Push Play’ awareness and uptake. Key
informants said research showed Feeding Our Futures “seems that it’s hitting the target
group” and that children in the Fruit in Schools programme have been shown to be
eating more fruit overall in the day.
Many DHBs are evaluating programmes through access to the HEHA Evaluation Fund,
but many of these have not yet been completed. One DHB key informant said
monitoring was an area that needs to improve in the future, with baseline data and
planning how to monitor change, but time constraints are a barrier to this, and at
present, they were mainly relying on general feedback and anecdotal evidence.
Monitoring may also be more focused on “activities and what’s happening” than
outcomes indicators. One person referred to narrative reports from the DHB’s Māori
Community Action Project which showed
things like the kapa haka groups, they’re changing what they’re eating,it’s fruit and
it’s water. It’s building on what they had already started, but being directly
involved in this HEHA initiative, they’re more aware and they’re more focused.
There’s some really good results coming from that. Losing weight, so a combination
of the physical activity and diet.
It was suggested by a Ministry of Health key informant that another sign that HEHA is
producing positive outcomes is that “DHB boards are continuing to invest [over and
above HEHA]…now they don’t do that if nothing’s happening so I see that as positive.”
Other evidence cited by key informants is anecdotal, such as hearing that garden
centres are selling more vegetable plants, and unquantified, such as the perceived
changes in public awareness.
A number of reasons were put forward as to the lack of evidence at present as to the
outcomes HEHA has produced. The first is the need for time before changes will be
apparent: “I think some of these things that HEHA is attempting to turn around are
societal trends, a bit like a very large ocean liner, that they don’t turn around in a short
while.” This was likened to other public health issues: “I think we also need to be
conscious of the context and that it takes, it took two decades for us to get where we are in
tobacco so this is not a short-term game”, and the need for “that leap of faith that this is
going to work long-term” to produce population gains in the future. Key informants also
considered it was too early to be expecting outcomes “when funding really only started
in 2006…and HEHA has not been fully funded or fully implemented”, and that “Research
shows it takes 7-12 years to execute behaviour change and monitor it. I think the
programme needs longer investment so that we actually see the long-term benefit.”
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A second difficulty in assessing outcomes is the problem of measurement. While
national surveys give snapshots in time, getting “real time measures” is difficult. There is
also the question of what to measure: “The percentage [of schools] that have taken the
coca cola out? What percentage of schools are willing to make it a totally healthy food
environment? We haven’t kept any of that kind of stats.” A further aspect of measurement
is its acceptability. One DHB had considered getting baseline BMI data in schools in
order to be able to assess changes over time, but this was rejected on the basis it would
single children out. Another difficulty is trying to interpret population outcomes of
public health activities at an individual level.
Since some outcomes may take some years to see, outputs may be a preferred or
intermediate measure to outcomes. Key informants in three DHBs mentioned using a
programme or intervention logic model to look at what the long-term goals are, and
what actions and results can be measured as contributing to that, but
It’s difficult to measure that, though, in the sense that how much can a step
towards an outcome be considered to be, first of all measureable, and secondly
reliable, either as the actual indicator or as the proxy towards an eventual
outcome? So we probably struggle on that as much as others do.
This leads to another difficulty: in common with other health promotion activities, it
may be hard to attribute outcomes directly to HEHA, given the multiple factors that are
influencing people’s eating and activity. “I don’t believe we’ll ever be able to say a
particular initiative made a particular difference, actually…but we know that the mass of
or the sum of these ways of doing things,… international evidence says that they’ll make a
difference.” There is again the time factor and many steps between a personal change
and a longer term outcome: “We had parents reporting their children spending less time
watching TV…but whether or not that has an impact on those goals down the line, it’s a
long, long chain in between.” Accurate attribution was also seen as a difficulty by one
Ministry of Health key informant in holding DHBs to account:
Potentially we can hold DHBs accountable for ensuring that all their CVD, cancer,
diabetes-diagnosed people have had BMI and have programmes around them if
obesity is an issue, but it’ll be really hard to hold them [accountable] for a health
outcome for the population when they don’t control for food supply, they don’t
control for regulation of what food and manufacturing industries do, they don’t
control social marketing or advertising. So that’s the challenge around HEHA. So
we are working towards how we can frame up accountability for DHBs so that they
are applying their resource in the right way and we’re also penalising them in a
way that’s fair if they don’t deliver.
A further aspect of attribution relates to the question of how much HEHA can claim an
outcome from the activities of other organisations which may contribute to HEHA,
although that is not their primary aim: “…if activity levels are going up, and they are
probably not, they are staying about the same, it could be the Push Play campaign which
sort of comes under HEHA but was not developed because of HEHA.”
A final factor, which may affect the outcomes of HEHA, is the current economic
downturn. Many feared those most vulnerable would not be able to afford healthy food
(and that any gains for Māori under HEHA could be reversed), but on the other hand,
68
one person saw the possibility of positive outcomes, “if people start growing their own
vegetables and walking more and having to tighten their belts a bit, they may not be
eating some of the foods they shouldn’t be eating.”
Asked to identify what had been most successful in producing change under HEHA, only
a small number of factors were mentioned. The first was the National Administrative
Guideline (NAG5), which was referred to by 11 key informants from all groups. The NAG
was considered to have made a strong contribution to changes in the educational
environment. One key informant from the government sector said, “I actually think the
National Administrative Guideline change for schools is probably one of the most powerful
things we’ve done.” This was linked to the general environmental approach to change,
which could also be fostered by Health Impact Assessments: “I’ve always taken the WHO
view that changes in the environment are the most powerful changes, so Health Impact
Assessment will lead to environmental change; the NAG has made environmental change.”
Leadership was again identified as a critical factor, including government leadership,
leadership from the Ministry of Health (including having a dedicated HEHA team),
leadership in DHBs and individual commitment.
Certainly in some areas it’s worked extremely well and it’s probably way beyond
our expectations, and other areas it’s been much slower. It seems to relate
particularly to…commitment and leadership from higher up in the organisation where you’ve got a committed board and a CEO, things are going really well. Where
you haven’t, they struggle, which is probably not surprising. So it’s variable.
However one key informant from a government agency commented that the key to
success was “robust, solid delivery agents” such as DHBs and regional sports trusts, and
that while “you can give all the leadership in the world and all the resource support and
the direction…it really is those delivery agents that will make or break this.” Achieving
buy-in and ownership of the Strategy by these players will therefore be critical.
Collaboration also features again as an important success factor. Another is having
community buy-in and community-driven programmes. Key informants hoped a
‘tipping point’ would eventually be reached in society where individuals and
communities are willing to embrace the necessary changes and sustain change
themselves – but it did not seem that this point has yet been reached.
Synergies and linkages with other health promotion messages were considered useful.
Having specific funding for HEHA is important to DHBs, and one Ministry of Health key
informant considered, “From what I’ve seen, devolving the funding as low as possible
seems to be an important factor.”
Only a few barriers to success were raised. Those mentioned were the removal of the
NAG5iii, an NGO key informant’s perception that the Ministry of Health was not
collaborating well with them, and some workforce shortages. One DHB key informant
also commented on a risk for them of engaging with the community and other partners
to deliver a centrally-driven Strategy which might not fit local expectations, and of the
possibility of losing relationships if funding is withdrawn:
69
…one of the worst things you can do as a regional funder…is put money into a
community which establishes what is seen as sustainable programmes and jobs and
positions and then all of a sudden have to withdraw from that. That destroys any
goodwill that exists between us and the community.
3. Improvement/Development of the Strategy
The ‘HEHA’ Strategy was originally named ‘Healthy Action – Healthy Eating’ when the
draft was developed in February 2002 .(46) Nine consultation meetings were held,
including one fono and three hui .(40) Overall, consultation feedback was described as
being “generally very positive” about the Strategy .(40,p12) Following the consultation
process, the most noticeable change to the Strategy was the rearrangement of its title,
putting ‘eating’ before ‘action’. A summary of feedback on the consultation stated, “The
weight of feedback suggested that the goal of improving nutrition should be given the
greatest importance in the strategy” and that while this was the first goal of the
Strategy, participants in the consultation considered it was given “second place
throughout the document” .(40,p13) The other major changes from the draft to final
versions of the Strategy were the removal of three “Guiding Principles” (integration,
coordination and collaboration, and life-course approach) from the final HEHA
Framework, and renaming the key priority “disadvantaged groups” as “lower
socioeconomic groups” .
During the interviews carried out for this research, key informants suggested a number
of ways in which the HEHA Strategy could be improved going forward. However, most
people seemed to consider the Strategy as a good initial platform to work from, whilst
needing to be refreshed regularly as things change. The one contrary view was an NGO
key informant who suggested completely starting again and consulting “properly” rather
than trying to get retrospective buy-in from people who felt the original process of
developing the Strategy and Implementation Plan had been flawed.
Key informants mentioned that they would like to see duplication and fragmentation of
activity reduced, while work needs to continue on building engagement and
collaboration around the Strategy. Ministry of Health key informants acknowledged the
need to build stronger links with NGOs, some government agencies, and with local
government. Ministry key informants also considered they need to be clearer about the
role other agencies can play and the nature and purpose of engagement with them, and
to try to help non-health sectors recognise and value the contribution they can make to
health benefits. Stronger action-based alliances with the commercial sector were also
advocated by one person in order to embed HEHA within “our normal markets and
structures, rather than having it as a government add-on.” Continuing to maintain and
build on community activity was also viewed as important and a way to ensure the
longevity and success of the strategy, if communities themselves see the necessity of
and take responsibility for change and action.
70
NGO key informants in particular spoke strongly about their desire to see more
emphasis on environmental change, including stronger social marketing and regulation
of advertising and sponsorship linked to unhealthy food. Existing legislation about
advertising could be more stringently applied - “If you read the Advertising Standards
Authority’s codes of practice, if you actually apply that according to the word, you would
remove all of the junk food advertising at the times where kids are watching TV.” This key
informant also sought improved food labelling which is simple for the community to
understand.
There was a call for good evaluation of all HEHA activities to ensure we know what
works, and to stop funding anything ineffective. It was also suggested by one key
informant that HEHA could do less, but better, by reducing the number of activities
being undertaken, evaluating them well, then adjusting them as required to be more
effective.
DHB key informants had a number of things they wanted the Ministry of Health to do.
They asked for a clearer, long-term vision for HEHA, and certainty about on-going
funding. (One PHU key informant also sought security of funding in relation to Fruit in
Schools.) They would like less “micro-management” and greater flexibility in how they
are allowed to implement HEHA, including suggestions they might streamline the
required steering groups, better determine their own community needs and priorities
for funding, and link HEHA more closely with other broader health
promotion/population health work. In a practical vein, templates for contracts,
memoranda of understanding and terms of reference for interagency partners would
save a lot of time for DHBs, and they would like less paperwork and administrative
burden. The need for more Māori health promotion resources was also noted.
Early communication from the Ministry of Health (and other government agencies)
about decisions and changes would be appreciated, along with notification about new
resources that are becoming available. Greater back-up from central government
departments is sometimes desired, an example being a McDonald’s promotion of
pedometers in schools, which in one area was apparently marketed as being “in line
with the Ministry [of Education] even though it had no Ministry logo and no connection
whatsoever.” When made aware of this, a DHB HEHA team member rang the Ministry to
find out if this was true, and was told it was not, “ but they did nothing and they wouldn’t
do anything – to just say to schools this is not supported by the Ministries of Health or
Education…but that’s the type of leadership that we need.”
Some DHB key informants would like to see the Ministry of Health linking into national
events (such as a sporting or cultural event) rather than expecting the region in which it
is taking place to fund HEHA promotion for the occasion (although recognising local
agencies would be involved too). Clear linkage of the HEHA brand with all HEHA
activities would help DHBs to promote them and reduce community confusion. For
example, the ‘Feeding our Futures’ campaign was noted to lack the HEHA logo. Finally,
there was a call for greater support for schools and help for them to make changes easy.
Good work has been going on in early childhood settings and primary schools, but
71
secondary schools were identified as needing more attention, and “The school
environment in secondary schools seems to be much harder to change”.
In addition to suggesting improvements to the Strategy, key informants also identified a
number of ways they saw it could develop. They envisaged continuing to work at all
different levels, with multi-pronged actions, “So you’re not doing just one thing, putting
your eggs all in one basket, but doing different actions that often complement, often
synergise with each other.” The actions in the Implementation Plan would continue to be
progressed, with more attention on those which have not had much attention to date
(one person mentioning food security in particular should be addressed more). A focus
on vulnerable populations is expected to be maintained, including the currently
identified priority groups, but recognising other needy groups as the population
changes.
There was a wish by three Ministry of Health key informants to strengthen the
relationship between HEHA and primary and secondary health care. A DHB key
informant would like to empower their PHOs to have a greater role in managing HEHA
activities, and another DHB key informant said it would be important to have all health
professionals taking every opportunity to convey HEHA messages to patients, and to
integrate HEHA into other service areas such as mental health and oral health.
One DHB key informant spoke about the possibility of HEHA being managed regionally
in the future (across several DHBs in the area), and perhaps led by the regional public
health unit. A regional approach could streamline governance groups and collaboration,
reduce duplication, and free up “more resource to put on the ground.” A key informant in
a second DHB also wondered about a greater public health role in the future, but both
were uncertain whether public health units would have the capacity to pick up and
sustain all the HEHA work. Key informants in two PHUs also expressed a desire to see
PHUs playing a greater role.
Three key informants within government agencies spoke about the possibility of using
an approach like the French EPODE model (Ensemble, Prévenons L’Obésité Des
Enfants) which focuses on reducing obesity in childhood (47). In this approach,
leadership is taken by Mayors, but communities (involving all stakeholders) decide on
what actions they want to take and then participate in undertaking the actions, with the
provision of support, training and resources to do so. Evidence for the effectiveness of
this approach would need to be considered alongside the different approach being
taken by HEHA (with implementation through DHBs rather than local government).
Key informants noted that consistent messages about nutrition and physical activity
need to continue. Some people consider the next phase of HEHA may involve more
emphasis on physical activity to balance the stronger emphasis nutrition has received to
date, and also because this is perceived to be an area the new government will want
more focus on.
Overall, there was uncertainty throughout the sector about the implications for HEHA
as a result of new policy directives - “Until they make any decisions, we don’t know what
72
we can do” - and fears that any gains to date could be lost “if the momentum isn’t
maintained.” On the other hand, it is hoped that longer term, HEHA will simply become
something society accepts and everyone is doing, incorporated into daily life and into all
aspects of DHB work.
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3. Māori response to the Implementation of the HEHA Strategy
a. Introduction
This report explores the views of several Māori policymakers and advisors who were
closely involved in the development of the national HEHA Strategy. This data has been
analysed according to the four key evaluation research questions which focus on the
likely effectiveness of the HEHA Strategy for Māori and against seven key principles which
comprise the Māori conceptual framework for the evaluation (discussed below). The
report concludes by providing some recommendations both for the commissioners of
the research and the health sector more widely.
b. Methodology
The Māori conceptual framework for the evaluation was developed by Māori advisors on the
wider HEHA evaluation project and draws on He Korowai Oranga: the Māori Health
Strategy, as well as on Mason Durie’s Te Pae Mahutonga,(23) Hua Oranga, (24) and He
Taura Tieke (25). The key principles of the evaluation framework are: Māori
Development; Māori Autonomy; Māori Delivery; Māori Leadership; Māori Integration;
Māori Environmental Perspectives; Māori Responsiveness (Table 1 under Discussion
Section). The conceptual framework was used to inform interview schedule
development with questions relating to the seven key principles included in each
schedule. An analysis comparing results against the seven key principles has been
developed in the Discussion Section.
The development of the Māori interview schedules was also informed by the schedules
developed for the wider evaluation. Questions were adapted in order to make the link
between these and the Māori conceptual framework, Te Tuhono Oranga. A range of
interview schedules was developed depending on the participant’s role in the HEHA
Strategy. For example separate schedules were developed for MoH staff, staff of other
government Ministries and Crown Entities, for Sector Steering Group members, and at
an implementation level, for DHB staff (attached as Appendix One). All schedules
broadly covered four key focus areas; (a) implementation of the national HEHA
strategy, (b) outcomes achieved through the implementation, (c) areas identified for
improvement and (d) value for money. Sub questions were also included under each
focus area.
Selection of Key Informants
Informants were selected based on each participant’s involvement at a key policy level
with the national HEHA strategy. Selection was informed by documentation provided by
senior researchers involved with the wider HEHA evaluation that identified
membership on key advisory bodies and key policy people within the Ministry of Health
and other government departments. In addition we used a snowball approach where
key informants suggested names of others we could contact who, in their view, would
be able to answer the questions developed for the evaluation.
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Interview Process
The interviews with policymakers/advisors were conducted by two Māori researchers
between December 2009 and January 2010. A total of 17 Māori key informants were
approached to be interviewed however, of these, only ten consented to be interviewed
and were available in the requisite timeframe. Four participants were members of the
National HEHA Māori Caucus, two were members of other national, health-related,
advisory boards and the HEHA Sector Steering Group, three participants were
government department employees, and one participant worked for a Crown Entity. All
Māori Caucus participants had been, or are currently, in health promotion roles in Māori
providers or with DHBs. Participants were initially contacted by the lead interviewer
through telephone calls and/or by emails. The majority of interviews were conducted
on a one-to-one, face-to-face, basis although two of the interviews were conducted with
two or three others present. Two interviews were conducted by phone. Interviews were
tape-recorded and transcribed verbatim.
Analysis
Each transcript was initially reviewed by the lead interviewer and draft themes were
developed under each interview question. A team of four senior researchers from
Whakauae Research for Māori Health and Development (WRMHD) then reviewed the
transcripts and draft themes and synthesised a second, draft analysis, for full team
review. The discussion section was developed by the four researchers collaboratively
identifying and discussing key learning from the data. Transcripts were analysed
thematically against the interview schedules, to draw out the key messages. Analysis
also identified additional themes inductively. The themes which emerged from this
were considered and grouped under the four key foci of the main evaluation (discussed
above). The analytical work was strengthened through the critical input of Whakauae’s
research team.
The analysis matrix linking the findings from the data with the Te Tuhono Oranga
framework’s seven key principles was developed by researchers from WRMHD
reviewing all the raw data; reviewing the synthesised data; and discussing the
alignment of the research findings with the evaluation framework. Three categories
were used to describe alignment with the principles; (1) Yes, had met principle; (2) Had
partially met the principle; and (3) No, had not met the principle. The themes were then
linked into the Te Tuhono Oranga Framework and presented in table form.
Limitations
WRMHD was engaged to carry out the Māori stakeholder interviews approximately one year
after the initial round of interviews with non-Māori and Pacific peoples was conducted by the
wider HEHA Strategy Evaluation Consortium. During that year funding for components of
the HEHA Strategy was re-prioritised. The Māori interviews WRMHD conducted were,
therefore, undertaken in isolation from the wider research making it difficult to compare and
contrast views across all population groups. In addition, participants found it difficult to
75
recall details of the implementation due to time lag between implementation and data
gathering. More significant however, was the impact of these policy decisions on key
informants who, as a consequence of the shift in policy focus felt they had “moved on from
HEHA” or who used the interviews as a way of “debriefing”. It is possible that, under these
circumstances, participants primarily recalled only the negative aspects of their experience
and were not able to engage more fully with the possibility of future developments for the
HEHA Strategy. This limitation may be mitigated with further data collection being
considered in the first half of 2010. Additional data would seek the views of Māori at a DHB
and community level, allowing us to canvas more fully the views at a regional and
community level.
c. Results
1. Implementation focus

How has the HEHA Strategy been implemented?
Role of Māori Policymakers
As noted above, ten Māori policy-makers/advisors participated in the key informant
interviews. They included members of the National HEHA Māori Caucus, members of
other national, health-related, advisory boards and the HEHA Sector Steering Group,
other government department employees, and a Crown Entity employee.
The ten key informants worked, in their paid employment, in different health and
health-related Ministries and agencies, hence their role in the HEHA Strategy was a
strategic one as opposed to an operational or implementation one. Their focus was to
drive, from a public health perspective, the significant inclusion of Māori approaches in
the development of the HEHA Strategy and the Implementation Plan. Two critical
components of this role were strengthening the HEHA-related Māori workforce and
supporting Māori community development.
The Engagement of Policymakers and Māori Stakeholders in the Strategy
Perspectives on the level of engagement which occurred in development of the HEHA
Strategy and Implementation Plan varied among those interviewed. At one end of the
continuum, it was believed “… it [engagement] was well done” insofar as opportunities
were made available to Māori stakeholders to participate in the initial development of the
Strategy through a process of consultation. A draft document, for example, had been
made available to Māori District Health Board members and “…it went out for a wider
consultation around … well, testing groups I think we called it”.
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Extensive consultation had previously been undertaken by the MoH in the process of
developing the Māori Health Strategy: He Korowai Oranga;(19) a Strategy document
which was subsequently used by the MoH to inform design of the HEHA framework. It
was felt that, because HKO had influenced the development of the HEHA Strategy so
strongly, there was no need to “… reinvent the wheel ... [instead] just use what we have
got” rather than repeating an intensive consultation process. It was the view of one
informant that consultative opportunities for Māori input had existed from the early stages of
HEHA Strategy development.
At the opposite end of the continuum other informants commented that, rather than
having had opportunities for input, the Strategy “...was done before whānau had even had
input… that’s why things don’t work. It’s a top down approach rather than ground up” and
that “... there wasn’t a space for Kaupapa Māori or Māori development or capacity from
the top” .
One informant summarised the key role the MoH played in fundamentally shaping and
driving the Strategy by describing the MoH as being “... the mother that gave birth to
HEHA really. If I think about Pete Hodgson as being dad. They had developed the Strategy”
.

Has the implementation of the Strategy incorporated the principles of He
Korowai Oranga?
As noted above, while ostensibly He Korowai Oranga was drawn upon heavily to inform
the development of the HEHA Strategy, there were differing opinions among those
interviewed as to how effectively He Korowai Oranga principles have been incorporated
into the HEHA Strategy’s Implementation Plan.
In 2004 the MoH convened a Māori Caucus to inform the development of the HEHA
Implementation Plan and to specifically provide a Māori perspective on the Plan. The
Caucus met 3-4 times over the course of approximately one year and were successful in
incorporating He Korowai Oranga principles into the Implementation Plan. Then, with
finalisation of the Plan in 2005, the Caucus was disbanded. It was subsequently
reconvened in 2008 to review progress with the Plan.
Translating the HEHA Implementation Plan into concrete activity ‘on the ground’
became the responsibility of a raft of health providers across a number of levels of
intervention with oversight through DHB HEHA Project Managers. The ability of these
providers and practitioners to develop and deliver initiatives consistent with the
principles of He Korowai Oranga varied widely. Factors impacting on their ability to deliver
HEHA programmes consistent with the principles of He Korowai Oranga included the
providers’ own links to Māori communities, whether they understood Māori approaches to
health and wellbeing and whether they were culturally competent to deliver so-called
‘kaupapa Māori’ health services.
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Similarly, the understanding of, and commitment to, the principles of He Korowai
Oranga varied widely amongst HEHA Project Managers, who were the key drivers of
HEHA implementation. The reliance on HEHA Project Managers, with varying degrees of
understanding of the principles, to appropriately manage and implement the Strategy was
regarded as potentially damaging for Māori communities. A suggested alternative was:
Implementation funding put aside for … Māori to determine a process
of what the Strategy means for them and how it might be implemented
through Kaupapa Māori services …. Something built alongside [the
DHB HEHA structure] that at the same time allowed for those other
Kaupapa Māori services to determine ... their approaches … we need
like a Hauora renaissance .
One informant commented that a mechanism for helping to ensure effective
implementation, consistent with the principles of He Korowai Oranga, was the Māori
Community Action Project. This Project was funded by the MoH and included coordinators
in some DHB regions to work alongside DHB HEHA Project Managers. One key
informant described the role of these coordinators as being particularly critical “… in
terms of engaging community and getting buy-in from communities … instrumental in
making a difference for Māori”. How DHBs chose to utilise Māori Community Action
Project funding and a more detailed analysis of HEHA co-ordination roles at a DHB level
may be followed up by another round of interviews; there appears to be some regional
variation and also some confusion over terms used for various positions.

Provider and workforce development - How was this addressed in the
Strategy?
According to informants, HEHA capacity was increased primarily through appointment of
DHB HEHA Project Managers and, in some areas, Māori Community Action Project
Coordinators. The facilitation of both Māori provider development and Māori workforce
development, which in turn were regarded as enhancing HEHA capability across all
sectors, were key tasks for those appointed to these positions. One informant noted
that having the coordinators in place was a particularly effective use of resources as
these people had the skills and community connections to “hit the ground running ”.
Several interview participants challenged whether DHBs were the best place to
concentrate the increase in HEHA capacity, particularly if the overall Strategy was
aiming to impact cross-sector capability. One informant commented that:
…looking at a Māori health provider that’s in Māori communities with
access by Māori communities, I would have thought that injecting
some funding there would be more beneficial … the provider might not
have the capacity straight away but you’re just short-changing it if
you’re not going to represent some capacity building around it .
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Another agreed further noting that “… the priorities of the DHB [overshadow] the
[interests of] priority population groups being Māori and Pacific” .
Beyond the public sector, a strong contribution to Māori workforce development was
identified as having coming from “… organisations like Te Hotu Manawa Māori [which]
have been really effective in trying to have a leadership around the [HEHA] workforce
development … to respond to …big strategic issues”.
Additionally, it was noted that some Kaupapa Māori providers were already operating
effectively across sectors prior to the advent of the HEHA Strategy. These providers had
existing capability which meant they were well-positioned to take full advantage of the
opportunities available to their communities through the HEHA initiative from its inception.

Leadership - Was Māori leadership appropriately engaged and evident in
the implementation?
Leadership was identified as having emerged at a number of different levels. Several
participants indicated that implementation leadership was a MoH function with “… their
role as being kind of the glue, if you like, at national level, making sure that the whole
package of activities was contributing to the strategic priorities and outcomes”.
Te Hotu Manawa Māori was identified as having provided pivotal Māori leadership around
effective implementation of HEHA in Māori communities. One participant also observed that
an element of leadership was demonstrated by national advocacy group Agencies for
Nutrition Action, which worked to get effective HEHA implementation responsive to Māori
communities occurring within mainstream NGOs, such as the Cancer Society and the Heart
Foundation. This leadership however, was not specifically Māori leadership.
Leadership at regional level was identified by a number of participants, including MoH
and DHB key informants, as being the role of the 21 DHB HEHA Project Managers.
Providing or facilitating this leadership was, however, compromised according to
informants by the fact that only three Project Managers identified as being Māori.
Furthermore, not all HEHA Project Managers had a reducing inequalities focus or an
understanding of, or background in, public health and health promotion approaches. From
2007, however, HEHA Coordinators were funded in each DHB. These practitioners were
regarded as having the skills and connections to provide and/or facilitate local Māori
leadership.

Collaboration, coordination networks and partnerships across
stakeholders –In what ways did the Ministry of Health engage and partner
with Māori communities?
Key informants noted that collaboration, coordination and partnerships were important
factors in ensuring the success of the HEHA Strategy. The role of the organisation or agency
determined to what degree collaboration and coordination occurred. Generally key
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informants agreed the MoH’s role was one of strategic leadership whilst “coordination and
implementation was the DHB one” .
I guess I saw the Ministry’s role ... they were to lead the development of
the Strategy, and to ensure that the right focus was within the Strategy
and that they had Korowai Oranga threaded through there. And the
focus on reducing inequalities was there as well .
In the period 2004 to 2008 a number of collaborative entities were instigated by the
MoH to inform the implementation of HEHA and its subsequent review process. Three
such groups were the Reference Group; the Māori Caucus; and a Pacific Caucus. A
Sector Steering Group consisting of representatives from government departments,
DHBs, NGOs, Māori and Pacific communities, the food industry and experts from the
nutrition, physical activity and public health sectors was also established to provide
strategic direction and support to the national HEHA network and district HEHA
coordination. This Group also provided expert advice to the cross-Ministerial
committee(48).
To support its HEHA Strategy, the MoH also nurtured a number of inter-agency
partnerships during this period. Chief amongst these was the partnership of the MoH,
SPARC and the Ministry of Education. SPARC was the lead government agency for the
promotion of physical activity whilst the MoE was considered an important partner to
enable access to children and their whānau. The partnership was formalised in the 2004
Tripartite Agreement.
DHBs noted that the HEHA Strategy allowed them to both build on existing
relationships and develop new ones. The DHB’s ability to build new relationships and
cement old ones was further enhanced with the creation of HEHA Project Manager
positions in 2007 and HEHA District Coordinator positions in 2008. The HEHA Strategy
also allowed NGOs to work together across sectors in ways that had never happened
before:
…[Māori Caucus members] came from a much broader range of health perspectives,
community perspectives.

What were some of the challenges when it came to collaboration between
the MoH and Māori communities
One aim of the HEHA Strategy was to develop a “whole-of-government” approach to
improving nutrition and physical activity, which consequently required collaboration
across sectors and between organisations that did not usually work together. For some
key informants collaboration had not gone smoothly. The 2004 Tripartite agreement
was cited as an example of this, as the relationship between the Ministry of Education
and SPARC was described as “tenuous right from the word go”.
One of the biggest faults of all was that Ministry of Education didn’t
operate in the same sense as health. Māori, Pacific targeted population
80
groups was not their approach so the minute you start looking at a
Māori, you know implementing effectively for Māori, if you can’t get
the national bodies to engage at that level and say we are going to do
something that looks at how we reduce obesity for these groups. It
wasn’t their priority.
Other key informants were critical of the way Māori providers had been overshadowed
by the introduction of the HEHA Strategy. Whereas HEHA was regarded as a central
government and a MoH initiative, two informants noted that Māori providers, under the
auspices of other contracts, were already delivering “ healthy eating, healthy action
programmes, contracts, activities throughout the country” and felt the strategy was “like
over kill for stuff that programmes and activities were already achieving”.
Some key informants noted inconsistencies in the quality of collaboration between
DHBs noting that good collaboration was dependant on who had the key DHB HEHA
Project Manager role, their previous experience and how well they knew their
communities. One participant noted “you could actually see the disparity…if you had
strong advocates, HEHA facilitators within your DHB … you know it went back to, “well
who is your HEHA facilitator, how well placed are they?” .
Some NGOs also found it challenging to work collaboratively to achieve a common
purpose; “initially there was a bit of fighting around who should get money to do what
and whose disease was more important”. However, this improved over time.
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
What were some of the positives that came out of the collaboration?
Whilst there were many challenges in working collaboratively, key informants reported
many positives as well.
The HEHA Strategy required collaboration between
organisations and across sectors in order to work, and as implementation progressed,
organisations did become more familiar with working that way. One respondent
described a “kind of a rallying of the sector, a sense of common purpose” whilst another
commented that a strength of the HEHA Strategy was that groups were “working
together where they would never work together before”.
The Māori Caucus also provided opportunity for members to work across sectors. One
key informant believed the HEHA Strategy complemented other strategies such as the
Ministry of Education’s Kahikatea Māori and both Te Puni Kokiri (TPK)’s Realising
Māori Potential Strategy and their Whānau Ora Strategy. One respondent stated that “it
was really exciting to have their [TPK’s] involvement and they were very supportive of
HEHA…and keen to have a much closer working relationship”
Several key informants noted that at a DHB level gains had also been made. Links with
Māori communities had improved as a direct consequence of the HEHA Strategy
through interventions such as the HEHA Project Coordinators who “in terms of engaging
community and getting buy-in from communities, were instrumental in making a
difference for Māori .

What sorts of policies, approaches and initiatives worked best and why?
What did not work so well and why?
Several informants made reference to the rigid nature of the Strategy particularly with
regard to timeframes, with one participant stating “the Ministry’s strategy; the Crown
Funding Agreement is very explicit, very prescriptive”. This was not the case however,
with implementation of the Strategy by DHBs which varied from region to region. A
Strategy component, Māori Community Action, allowed some DHBs to support
initiatives that were driven from a community level. This fostered a greater degree of
local engagement, wide community buy-in, and provided funding that appeared to make
a difference at a whānau level.
And some worked really well and just well done to those DHBs who
actually listened to what their community was saying they wanted to do
and allowed them to do it ... That’s why things don’t work. It’s a top
down approach rather than ground up. What you want, all of those good
health promotion practices that we’re brought up on as kaimahi on the
ground .
Another component, the appointment of HEHA Project Coordinators, had also been
instrumental in making real changes in some DHBs. These Coordinators had gone about
forming relationships with their local iwi, which in turn, enabled them to work proactively in
the allocation of funding.
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2. Outcome focus

How effective has the HEHA strategy been?
The HEHA Strategy had attempted to include a focus on Māori health outcomes by
incorporating aspects of other well accepted Māori health frameworks such as He Korowai
Oranga. One respondent described the process as developing “Māori specific outcomes
and actions based on those four pathways and then integrat[ing] them back into the HEHA
framework”.
Several respondents spoke about the establishment of a Māori Caucus and the role this group
played in incorporating a Māori worldview into what was regarded as an essentially
“mainstream” policy. The Māori Caucus was regarded as being able to provide Māori advice
as the Strategy was being implemented, which added strength to the work of Ministry and
DHB officials.
In terms of our implementation ... you know we recognised that we
needed Māori advice guiding us down that pathway and so we had the
Māori Caucus alongside us and I think that just added strength to what
we were doing and ... in terms of what was happening with our projects .
The Strategy was considered by one participant as integrating Māori principles very well:
We saw it as being one of the best mainstream kind of strategies to come
out of the health sector in a long time, which bought in all of those key
elements of environments, people engagement, service reorienting
funding, we thought it was pretty damn good .
However, there were mixed views on how effective the Strategy was. Some participants
thought it was very effective at clearly defining a vision for moving forward together, was
acceptable to Māori communities and provided a vehicle for resources to go out to
communities:
I think the real value of HEHA was not the Strategy or the tasks, but it
was this real sense of together we can do it, I have a role to play and I
can see my face and my role reflected in this comprehensive approach.
HEHA worked for Māori because it was an inclusive Strategy that looked
at a whole range of opportunities for them to actually play together,
socialise together, eat together.
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I don’t think the world was a better place as a result of it, it was just that
it harnessed resource and made it more effective or useful.
Other participants thought the Strategy was imposed on communities from “the top”,
was too focused on planning documents and was not that well targeted for Māori. For
example one participant commented that there were a lot of plans and focus on the Strategy
and “less time was spent in terms of where is actually needed in terms of getting people
active”.
I am not sure if it really hit the mark in terms of the outcomes for Māori,
Pacific and low income. I think some initiatives were still a one size fits
all and it came across as a one size fits all approach.
However, this view of a top down, one size fits all approach appears to have differed
from region to region; with those from some DHB regions being very happy with the
level of community engagement in the Strategy locally:
The difference with us here I guess is that our programme sought to
address right at that community level so it wasn’t about going out there
and saying you have to change, it was about saying we would like to do
these things, how best can we kind of…and build it in to what you’re
doing already.
Some commented on the effectiveness of the approach itself. While one participant felt
that the overall Strategy was not well thought through – being a series of “well
intentioned but poorly executed strategies” – others thought that the inclusion of a wider
population focus, including the need to change environments and address obesity
prevention from a whānau and community perspective, was a key strength. One
respondent noted that in their view “what I really liked about that was that it also had a
real long term focus in terms of changing the environment” .
At a community, and therefore an implementation level, a number of respondents noted
that what worked well was having passionate, informed and committed people at the
“grass roots” level who were able to translate the intent of the Strategy into
programmes on the ground. Health promoters who were able to provide practical advice
to members of the community about accessing HEHA funding, writing funding applications
and negotiating the bureaucracy of form filling were regarded as especially important
amongst rural or low-decile Māori communities:
She has done a fantastic job ... she’s assisted them with their application
process because we do have whānau who get hoha ...she’s gone in and
helped them, she’s directed them with the application process and I think
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... has gained huge kudos ... for herself by doing that ... that’s the feedback
that I have got ... she has supported the pre-application, during the
application and then goes back after the decision of our panel. Feeds
back and then she does a follow-up .

What changes have taken place for Māori peoples in terms of awareness in
nutrition and physical activity?
There were very positive comments about the uptake of the Strategy and reach and
awareness of the Strategy in a relatively short period of time:
I think it’s done incredibly…you know if I think about other strategies
and how long it takes to bed the strategy and how effective it’s been in
the short span of time, three years, huge gain .
People are really starting to get engaged and the buy-in is there. We
went to a hui out at Hutt, it was celebrating the Māori Action Projects,
the HEHA ones. But it was just amazing the turn out.
However, there were a number of participants who commented that the withdrawal of
some components of the HEHA Strategy will result in less coordination and integration,
the loss of the intersectoral focus, and a lessening of the national collective focus. For
example, one respondent commented that the “withdrawal of funding from the
education sector [meant] we have lost the traction completely” .
There is no strategy, there is no strategic direction. There is no
leadership. No one is sure who is in control of the helm anymore so you
have got all of these providers who are still differently resourced to do
something ... lost the sense of I am part of something bigger than just me.
And so everyone has now gone back to, I am just going to focus on my
little bit of the world and what I am supposed to do and what my
contract says I have to deliver and that’s what I am going to have to do .

What actual changes have taken place in the nutrition and physical activity
environments for Māori people?
There were many examples of short-term projects, cross-sector projects and longerterm programmes initiated under the HEHA Strategy for Māori communities. Some
participants commented that these were part of longer-term, Māori provider initiatives
developed over the last decade which had been strengthened by the addition of HEHA
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funding. It was unclear from the interview data whether these programmes had been
evaluated for outcomes such as change in BMI or pre and post intervention objective
measurements. However, one participant thought it was important to measure changes
in morbidity and mortality noting that a, “reduction in the rate of Māori death from
chronic illnesses would be great” . Most respondents identified that it was unrealistic to
expect to see these types of changes in the short term:
I think it’s too soon to have measured really the absolute gain it would
have resulted in. I think chopping off parts of it already has meant that
we will never get a clear sense of how effective that Strategy was .
I am not sure if it’s been able to realise the benefits of some of those
longer term changes.
Participants did comment on the evidence of changes within communities as many were
aware of positive feedback from programme participants and shared stories of success
“you know the guy who lost weight and then got his family to lose weight” . They indicated
that there was anecdotal evidence of changes in community cohesion and described
programmes that had been funded across sectors:
You had teachers and you know, principals of schools and parents
associated with schools saying ... “we think this is a really good
programme. It’s having a good effect on the children”.
The most successful thing is where we have seen the Community Action
Projects taking off and taking place basically ... that’s where we always
believe that success will come from.
In addition, participants noted changes in community capacity that may, in the longterm, have led to building research evidence, outcome measures and indicators:
Providing workforce opportunities, evaluation training. So they are
thinking about what it is they want from their project. What sort of
whānau ora outcomes are you looking for, how will we know, what are
the measures that we will put in place to know that were getting there.
Two participants pointed out the difficulty of translating broad Māori concepts of wellbeing
into measurable objectives and measuring obesity reduction in Māori programmes. The
discussion raised the question about who determines key success indicators in obesity
reduction programmes and what is valued by Māori participants:
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I think about the whānau ora model ... [it] was so wide in terms of not
being clear about what its expected outcomes and results were right
from the start. The measurement of that at[an] evaluation level, it’s a
wonderful programme, families learn about Tikanga and Te Reo and did
we reduce obesity for Tamariki, which is what the programme was
about ... they have got connected .
One is about tamariki ... reducing obesity for tamariki aged between the
ages of 9 and 13. So that’s quite specific ... the evaluation says it has
done some beautiful things and made some families much more
connected to who they are as Māori. But in terms of measure, how and
what reduction in obesity has happened, we can’t get a fix on that .
3. Improvement Focus

What might have worked better and what changes could have been made to
the implementation of the Strategy to improve outcomes for Māori?
Respondents offered a range of suggestions when questioned about what might have
worked better or what changes could have been made in terms of implementing the
Strategy. In essence, the suggestions for improvement fell into four broad categories:
engaging and communicating with the sector; leadership at the central government
level; how funding was allocated and administered; and issues around workforce.
Engaging and communicating with the sector
It was noted that greater engagement with Māori communities, Māori practitioners and with
the DHBs, in the early and developmental stages of the Strategy would have improved the
wider sector’s understanding of the Strategy and had an impact on how quickly it was
adopted. One respondent noted that even though the Māori Caucus was useful, it needed
to have been put in place much earlier: “the Māori Caucus was formed a little too late and
it was kind of a…we needed to have Māori meeting at the table together like that much
earlier on” .
Similarly better communication with the Māori community about the Strategy and its
implementation would have been beneficial:
They should really, for me they should get communities involved at the
beginning ... then if everyone is on, that they have participated right at the
start in the development of something, then their passion for it and to make
it work exists right there. Because their thoughts have been listened to .
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And I certainly think, in terms of going forward, we would need to look at
our engagement with Māori as well. Always looking at that and how Māori
are participating in our structures and how we are engaging with them.
You can always look at how you can improve that. And how are we
communicating with Māori, how are we getting information out there .
... so there was a whole pile of things that we didn’t do, that we would like to
have done, like engage with the Māori public health sector, like engage with
the Pacific public health sector, like engage community organisations that
worked in these areas .
Central government leadership
Better coordination and stronger leadership from the Ministry of Health was noted as
an area which could have been improved:
There could have been stronger leadership by the Ministry of Health in
that [Tripartite] Agreement to ensure that what came out of that was
consistent across each of those agencies. So when they talked about a
whole of government approach it was there but when it came to be
implemented we couldn’t really see it .
Funding
Respondents noted that improvements could have been made in the amounts of funding
provided, how and to whom the funding was allocated, the timing of getting funding to
communities and how the spending of HEHA funding was monitored.
While most respondents agreed that the HEHA Strategy was very generously funded
overall, improvements could have been made in how the funding was allocated to
different priority groups. One respondent questioned whether simply having more
resources would actually improve the situation in Māori communities because, in addition to
funding, workforce capacity and capability was also necessary:
Because if we had more capacity, and if the people who worked in the
programme had more capability at the start, we could have perhaps done a
lot more ... if you had more resources to put in you could have had more
programmes, but you could only have more programmes if you had more
capable people to run the programmes ... But yes, if we had more resources
we could have done more .
Having the funding for communities available earlier would have been a definite
improvement, as this participant noted “It took so blimmim long and that’s something
that shouldn’t have taken so long for that process and that funding to get to those
communities” .
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Another respondent noted that an improvement, particularly in terms of remaining
accountable to Māori, would have been to give the HEHA funding directly to Māori to
administer, through Runanga or Māori Trust Boards, as opposed to through the DHB. “What
is the best way to ensure accountability for the putea? ... I would dearly love to say “give it
to the hapū” but somebody has to manage that. You know for Māori by Māori? ... personally
give it to our Runanga, give it to a Māori authority” .
One participant noted that the uptake in the community and the possibility for change at
a population level would have been better had the funding “been able to be delivered in
the ways that it was described or prescribed”. This informant went on to note that, while
the uptake of Strategy had been “huge”, even greater improvements could have been
made as “collectively, we could have probably done that a little bit more effectively, faster” .
In terms of monitoring the funding allocated to DHBs, one respondent commented that
this should have been “done a hell of a lot more stringently” as a number of DHBs were
unable or incapable of using the HEHA funding for Māori appropriately. “A lot of them
have got off the hook of having huge amounts of money ... for delivery of a programme that
they never ever got on board and dealt with it effectively. Not from a Māori perspective
anyway” .
Workforce
With regard to the DHB workforce charged with leading the implementation of the
Strategy, respondents felt greater emphasis should have been placed on ensuring HEHA
managers were well connected with the communities the Strategy was targeting. In one
participant’s view, the Strategy was less about having specialist nutritionists and
dieticians leading implementation amongst communities, and more about using health
promoters with excellent community networks to implement the Strategy:
I really think the Ministry should have pushed hard ... [to] influence the
recruitment process that DHBs undertook for their programme
managers ...[In] Auckland, there is not one Pacific project manager for
HEHA when, if you think about the whole basis of HEHA was about
obesity ... DHBs definitely at the start saw it as a dietetics nutrition issue.
“We will get a dietician to do this. We will get a nutritionist”. And had
absolutely no idea how they would actually then go and mobilise
communities. Because that’s not the context they had worked in. They
would have been much better placed to pick up a fairly experienced
health promoter and put them in fast ... to get that traction happening
at that level .
However, another respondent noted that funding allocated to up-skilling the Māori and
Pacific workforce, specifically in the areas of diet and nutrition, disappeared as the
Strategy was rolled out:
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We had built a workforce development component into our Community
Action Project. And one thing we were disappointed about ... was, we
had some money for scholarships for dieticians, Māori dieticians and
Pacific dieticians to increase the numbers, and then we kind of ... that
seemed to have got lost. So that was disappointing .
Maximising the skills and expertise that were available in the community was regarded
as a missed opportunity in the implementation of the Strategy with another respondent
noting that a more structured approach to using the knowledge in the sector would
have been an improvement:
One of the things I was thinking about [was] ... to actually pull the hui with
the HEHA project managers who were Māori on a more regular basis. ...
have a structured approach to that. Instead of an ad hoc, just ring them up
when you want some advice. ... Thinking ok, let’s see how we can maximise
what they know, and their knowledge and expertise to inform what we are
doing at our end. And vice versa ... information sharing .

What changes could have been made to the HEHA Strategy or its
implementation that would help better achieve its vision and goals for
Māori communities?
The key informants noted a number of changes to the HEHA Strategy and its implementation
which would have, in their view, helped to better achieve the vision and goals for Māori
communities. Respondents queried whether providing more funding or targeting the existing
funding specifically at Māori communities would have been a more effective way of
achieving the Strategy’s vision for Māori, in part because this would build up the Māori
health workforce:
I would have thought that injecting some funding there would be more
beneficial than injecting funding at a higher level like the DHB for
example and ... sure, the provider might not have the capacity straight
away but you’re just short changing it if you’re not going to represent
some capacity building around it .
In terms of making a difference for Māori communities, would we have been
better to resource, would we have been better to look at effective Māori
providers who are already well and truly in touch with their Māori
communities eh? Would we have been better to resource them? .
Ring-fencing money for Māori and making the Strategy more responsive to Māori were
regarded by one participant as possible solutions to the concern that Māori communities
were, in some areas, missing out from HEHA funding. The participant stated that “I
would have really liked to see a whole lot of implementation funding put aside ... for Māori
to determine a process of what the Strategy means for them”.
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Greater leadership and better articulation of the vision were regarded as changes which would
contribute to achieving the Strategy’s vision and goals for Māori communities. As one
respondent noted “I think some areas of weakness have been around articulating what
the vision was so I don’t know that we always had a shared vision of that so ... I think there
were sometimes a leadership hole” .
Other changes mentioned by one respondent included more investment in research,
and in particular research into aspects of physical activity “What do we need to maybe,
beef up in the way of physical activity research?” along with a better interface between
public health approaches and clinical primary care “Bring the two together more,
prevention and early intervention. You know in terms of whānau ora” .
4. Value for money

Has the HEHA Strategy and its implementation resulted in value for
money?
Key informant views regarding whether the HEHA Strategy represented value for
money varied. Some noted that it was difficult to state whether the Strategy
represented true value for money as it was too early to tell the effect of the policy and
the cost benefit research had not been done yet so “hard to say, we haven’t done the
outcomes yet”. Others noted that it was difficult to quantify whether the Strategy
represented value for money for Māori as it was primarily as mainstream policy and it was
unclear how much investment has supported Māori programmes and how much had
supported generic programmes: “How do they determine how much went into the
mainstream and how much was set aside for Māori?”.
You know we can say “Ok we can quantify our Community Action Project”
because that was Māori specific, but it’s where it’s more generic. And so you
have got this lump of money but you can’t actually really say how much of it
is being spent on Māori ... overall it’s really hard to actually say “well out of
this, so much has gone on, being spent on Māori, spent on Pacific” .
Another informant commented that the process of allocating funding and of monitoring
DHBs complicated the ability to determine whether the government had received good
value for money from the Strategy. The informant noted that DHBs with the “most grunt
and push and power” were given carte blanche as to how they were able to use their
HEHA funding, with very little accountability back to the MoH as to whether their use of
the funding was appropriate. The lack of oversight of DHB use of the HEHA funding
resulted in large pools of unspent money or a lack of clarity as to whether funding
would be used for populations with the greatest need:
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They [the Ministry of Health] had the cheque book and they said here’s
the money and they said do it this way. I think DHBs ... they have
continued to be funded, despite the monitoring requirements that they
haven’t fulfilled over the last two years. And yet where they have gone
to, which is to see that they have channelled their funding towards
primary healthcare, PHO distribution. So they will just chop it up, shift it
out there with no guarantees about how that actually will result in
outcome for Māori .
Another informant agreed that there is a need to review how, and to whom, funding has
been allocated to assess whether funding has reached the right organisations stating, “I
think that allocation of funds to certain agencies to carry out parts of the implementation
needed strong review and strong process put in place”.
Other respondents indicated that they believed that the HEHA Strategy, and particular
initiatives which resulted from the Strategy, did represent value for money. One
respondent commented “Yes, in terms of its total investment compared to what it costs to
treat chronic diseases, I would say its value for money if you want to put it in that
perspective,”.
Yet another respondent noted that the HEHA Strategy did represent value for money if
the full range of beneficial outcomes which have resulted are taken into consideration:
I think anything that actually builds up people’s ability to take control of
their own lifestyles is value for money ... as far as I am concerned if they
can run programmes, I can measure our programmes, a healthy lifestyle
programme ... let’s say [name of local Māori programme] ... I could put
that against a GRX [Green Prescription] clinical ... we would still come
out the budget model compared to what they deliver and we would
probably have far better outcomes .

Overall how has the Strategy worked?
Once again, with respect to ascertaining whether the Strategy has been successful a
range of views were offered. One respondent regarded the HEHA Strategy as having
only “mixed success overall” due to the delays in Māori accessing the funding that was
available. The respondent commented that “in the beginning it was failing Māori, but
now that we are finally starting to see Māori communities accessing a piece of the apple
pie, its having success, we’re seeing success because we’re reaching communities” .
A number of respondents noted that, in terms of a “brand”, HEHA is well recognised and
known throughout the community. There is now a great deal of community support for
HEHA messages and these messages are being reinforced in venues not normally
associated with HEHA:
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In terms of reading how well HEHA is going, my husband ... he works in
the education sector and ... he said to me one day, ... “You know what? I
have been to 4 different hui today” and he said at each hui, HEHA was
talked about. That has to be a measure of success eh... That it’s out
there. The awareness is there.
The Strategy was also regarded as a success because people were “taking control of their
own health and wellbeing” , and children were aware of the messages and repeating
these to their parents.
Well, if you can call the messages that are getting through to my
mokopuna that they’re telling back to me a good outcome ... if that’s
happening in a whole lot of other households and that these healthy
messages are being somehow imprinted on the minds of mokopuna so
that they are coming home and telling their parents, I think that’s a
good outcome .
The HEHA Strategy has also been regarded as having helped “lend direction” and
“created some momentum” as this informant noted:
There has been a renewed sense of vigour, a sense … that we’re all
working towards something worthwhile and something shared and
something we can all own. And so I think that was the key success of
HEHA .
While respondents agreed that the Strategy, as far as it went, had met with some
success, it was also evident that environmental and structural change is required, not
only to support changes that have been made amongst whānau to date, but to ensure the
sustainability of the initiative and create permanent multi-generational change. One
informant noted “we needed to benefit from environmental change as well”, while another
commented that “you’re trying to shift the whole community and you’re trying to do it at a
political policy level”.
A third noted that food security for Māori will be an ongoing issue:
It has to do with affordability. Making the trade-off between buying the
good cuts or spreading the money you have further and buying other
things because the good cuts are going to cost you more. Which means
you will get the good cuts but you might not get the three veg... So even
though it seems to be taking off in families who can afford it, in the
families who can’t afford it and unfortunately the high deprivation areas
are where we live, that’s going to be a problem.
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d. Discussion
Key points from each of the sections covered in this report are addressed here. Along
with the Te Tuhono Oranga Evaluation Framework analysis offered in Section e. below,
this informs the recommendations which follow.
Implementation
Implementation of HEHA clearly relied heavily upon the engagement of key players
from the outset. Attempts had been made by the MoH to secure engagement through
consultation around the draft Strategy. This, however, was viewed by some Māori
outside the State sector at least as being ‘too little, too late’. Active participation from
day one would instead have sent the ‘right signals’ helping to ensure that the approach
would in turn be embraced at community level with minimal delay.
The work subsequently undertaken by the Māori Caucus, in development of the
Implementation Plan, went some way to bridging the earlier gap in Māori input. This
group was able to have some influence at Sector Group level and was able to drive the
critical inclusion of Māori world views in the Implementation Plan. The disbanding of
the original Māori Caucus following completion of its key tasks, however, meant that its
potential for driving HEHA implementation and providing overall leadership was never
realised. Instead this was left to HEHA Project Managers at DHB level many of whom
lacked the skill, knowledge and networks to effectively engage Māori communities.
Collaboration
Success of the HEHA Strategy, a whole-of-government approach, depended on effective
intersectoral collaboration with a diverse range of partners. While there were a number
of challenges with regard to collaboration; participants also reported successes across
some sectors and at some levels.
While some key informants were critical of the ‘top down’ approach taken by
government agencies, as this did not provide for appropriate levels of partnership and
meaningful collaboration, opportunities were seen to exist by others for effective crosssector interaction. Collaboration with cross-sector groups was fostered by groups such
as the HEHA Māori Caucus.
Collaboration was also facilitated by the close alignment of the HEHA Strategy with other
government strategies such as the Te Puni Kokiri strategy, Realising Māori Potential.
However, this alignment was not demonstrated in initiatives such as the 2004 Tripartite
Agreement, which was challenged by sector differences and priorities.
While there were improved linkages with Māori communities for some DHBs, regional
variation meant that this was not a consistent feature of HEHA collaboration. The Māori
Community Action Fund appeared to be one mechanism that provided an opportunity
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for DHBs to work more closely with their Māori communities and provided access to
funding that participants identified as having made a difference at a whānau level.
Collaboration was strengthened as the Strategy was progressed and participants
learned from trialling various cross-sector partnerships. Participants noted that
collaboration had improved to a point where sectors were rallying together and were
beginning to get shared understanding of the Strategy. This progress was halted in some
areas as changes to government policy resulted in what were potentially productive
cross-sector relationships being disbanded.
Outcomes
In summary there were, and continue to be, many challenges in being able to describe
clearly what the HEHA outcomes have been or are likely to be, for Māori. These include
some methodological issues such as poorly defined outcome measures, lack of
agreement on outcome measures, and in some cases lack of objective measurements of
obesity reduction. Sometimes linkages between actions and results, described as success
indicators by participants, may be tenuous and other causal explanations may be probable.
What appeared to be reported as overall HEHA Strategy outcomes by participants were
more short-term process and impact outcomes such as increased collaboration, greater
community engagement, evidence of uptake of HEHA initiatives and increased social
cohesion. Some evaluations of local HEHA projects sought to measure what participants
were valuing as culturally specific outcomes and these may have been different from
outcomes expected by the funder. For instance a sense of greater whānaungatanga was
valued as an outcome by participants, but may be challenged as a satisfactory measure
of obesity reduction by the funder. Some success had been measured anecdotally
through individual success stories and attendance at hui by participants, indicating
support for the Strategy.
The expectation of seeing broad environmental changes within a medium to short-term
timeframe is probably ambitious. Many participants agreed that the longer-term goals
of the Strategy were not likely to be seen or measured in the short term. Longer-term
goals such as a reduction in inequalities would need to be measured at a population
level and taken over the longer term in an environment that had sustained HEHA
funding. The causal pathway for the reduction in obesity levels between population
groups is also difficult to attribute to approaches such as HEHA initiatives. However, we
can say that the approach appears to have been targeted at Māori communities and that
may result in increased access to services and changes in Māori environments, which
may in turn impact on inequalities.
As some HEHA initiatives are cross-sector, the ability to influence outcomes from within
the health sector is challenging. In addition, changes to the wider national HEHA
programme, resulting in cessation or changes to some programmes, means we may
never be able to measure some outcomes. Participants commented that evaluation results
were starting to be reported when policy changes were made.
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While outcome measurement and building an evidence base is challenging there has been
some capacity building within Māori providers as part of HEHA initiatives. This may result
in providers being better able to identify programme logic and determine short, medium and
long-term outcomes, and acquire skills and knowledge to carry out the necessary evaluation
to determine effectiveness of HEHA initiatives.
During the interviews we noted an issue with dissemination of evaluation results as some
participants were unable to direct the researcher to published evidence of the outcomes
achieved by specific initiatives. Participants were aware of evaluations that were carried out
locally but generally were not aware of the results.
If evidenced by the number of Māori programmes funded, awareness and uptake of the
Strategy, and positive messages coming through both anecdotally and through evaluations we
can say with some confidence that Māori communities have been supportive of the Strategy.
However, this support has not been without reservations. The key concerns noted in feedback
were that the Strategy was a top down imposition on Māori communities; that it often relied
on local level leadership within DHBs to advance the Strategy resulting in variability in the
success of the implementation; and subsequent withdrawal of components of the
Strategy had adversely impacted on providers and communities who had already done
considerable groundwork in preparing communities for interventions and had set up
programmes only to find them severely curtailed or withdrawn.
Overall Success and Value for Money
In terms of whether the Strategy represented value for money, once again this was
difficult to ascertain in terms of changes in changes in levels of obesity or physical activity
as baseline clinical data was often not collected in communities prior to the Strategy being
implemented. However the HEHA ’brand’ is certainly well-known and well recognised in the
Māori community and Māori whānau and communities are much more aware of the need
to eat healthily and maintain a certain level of physical activity. The indications from
the interviews are that these messages importantly are also being picked up by
children.
Improved monitoring of how DHBs spent their allocation of HEHA funding, greater
involvement by Māori communities earlier on and, in some cases, greater autonomy and
control over funding decisions affecting Māori communities, would have made a difference
to how the community perceived and engaged with the HEHA Strategy. In the areas where
Māori participation in the HEHA programme was high, this was attributed to committed and
knowledgeable Māori health professionals, who knew, understood and were able to
articulate the public health and health promotion goals inherent in the HEHA Strategy.
Greater structural and environmental change to support the gains made to date and
how the messages and lessons learned will be sustained into the future were two key
concerns raised by respondents in deciding whether overall the HEHA Strategy has
been a success.
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Notwithstanding these two important provisos we would agree that the HEHA Strategy
has had some success in changing people’s views and attitudes towards healthy eating
and physical activity and has gone some way to providing a solid foundation for future
public health efforts to reduce obesity amongst the Māori population.
e. Te Tuhono Oranga Evaluation Framework Analysis
For all principles there was strong regional variation with some DHB regions performing
well against the Framework and others not having met the principles. It should be noted that
this is the first stage of data collection for the evaluation and results against the matrix should
be treated with caution. Not all DHB regions are represented and the sample from which the
data is taken is very small. However, having said this, there was a significant degree of
consistency within the data and the researchers have also called on their own knowledge to
inform analysis. This knowledge has been acquired through extensive work with Māori
providers, the health sector and more recently HEHA evaluation work. Through discussion,
and by debating examples from the data, a consensus on ratings was reached by the
researchers.
The analysis is summarised in Table 3 below. Only one category met the principle fully, and
this was Māori Delivery. All others partially met the criteria. Each category in the matrix is
briefly discussed below with examples of principles provided.
Māori Development
Promotion of healthy lifestyles was fully met within this category and participation by Māori
providers in the HEHA Strategy may have, in turn, enhanced wider participation by Māori in
society through employment; the enhancement of financial resources for whānau employed
by providers; training; and education. Access to a Māori world was enhanced in some regions
through kaupapa Māori programmes.
Māori Autonomy
This was very unevenly impacted. Some regions reported high levels of Māori control and
self determination in programme development and priority setting. At a central government
and DHB level however, we do not consider that there were high levels of control by Māori,
nor a great ability on the part of Māori leaders, politicians or policy-makers to influence
priorities.
Māori Delivery
Across all DHBs there appears to have been active involvement of Māori in HEHA service
delivery.
Māori Leadership
Māori leadership was considered limited at a range of levels including Māori senior policy
makers within government departments (possibly with the exception of the MoH) and at
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senior DHB levels. However, at a DHB level, some DHBs were particularly proactive and
Māori HEHA Managers were able to significantly advance Māori as a priority population.
Māori Integration
There was significant potential for this principle to be met with interdepartmental and crossgovernment alliances as well as NGO and Māori community networks being formed. The
potential was not fully realised however, for the reasons cited in this report.
Māori Environmental Perspectives
There were some examples of HEHA-funded initiatives that enabled Māori to connect with
nature, for example, mara kai and a number of the Māori community action initiatives.
Māori Responsiveness
There was strong responsiveness in some DHB regions with other regions performing poorly
on this principle. At a central government level there were actions to include Māori values
and principles through a consultation process; however, it seems that some of this was carried
out in less than a timely and appropriate manner.
Table 3: Te Tuhono Oranga Evaluation Framework
Principles
Māori
Development
Māori Autonomy
Components

Development of Whānau, Iwi, Hapū

Promotion of healthy lifestyles for Māori

Access to the Māori world

Enhanced participation in society by Māori

Māori control and self-determination in the
Evaluation
analysis
Partially met
Partially met
delivery of services/initiatives

Active Māori involvement in priority setting
and planning process
Māori Delivery

Active Māori involvement in the delivery of
Met
services/initiatives
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Māori Leadership

Māori leadership in developing, implementing
Partially met
and evaluating initiatives and research
Māori Integration

Active and positive links with aligned sectors to
Partially met
promote the health of Māori
Māori
Environmental
Perspectives

Developmental goals and aspirations should not
Partially met
impede environmental sustainability and the
broader Māori desire to connect with nature
Māori
Responsiveness

Mainstream is responsive to the needs of Māori
Partially met
f. Conclusions and Recommendations
As indicated in the discussion above, there is a range of successes and challenges for the
early implementation phase of the HEHA Strategy. Unfortunately, opportunities for learning
from this early roll out and subsequent evaluation may be lost as changes to government
policy impact on the scope of future HEHA activity. However, there are opportunities for
Māori policy advice to inform future national health promotion strategies. The feedback
provided in this report by key Māori policy makers/ advisors around the values and principles
of effective engagement is consistent with that described in Māori health frameworks, such as
He Korowai Oranga. In this sense, the feedback of these participants reinforces what has
already been clearly established and well documented.
As indicated in the analysis of outcomes met against the Te Tuhono Oranga Evaluation
Framework for HEHA Strategy development and implementation, the government has a way
to go to consistently meet the principles of effective health service provision to Māori. The
following recommendations are designed to assist government in better meeting the needs of
Māori and to strengthen future development and implementation of intervention strategies.
Recommendations
1. Ensure meaningful opportunities for Māori input are included from the outset in
development of strategies and related programmes. When convening advisory
groups, ensure terms of reference are well understood by all participants. Ensure
such groups are retained for an adequate period of time to ensure strategies are
well bedded in and meeting the needs of Māori. In addition, ensure a wide
representation on advisory groups including from a community practice level.
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2. Ensure ring fenced funding is maintained and strengthened to assist targeting of
HEHA interventions for Māori.
3. Increase the level of transparency and accountability for HEHA funds to ensure
investment results in the outcomes intended by the Strategy.
4. Ensure HEHA project managers have well established Māori networks, and the
confidence of Māori communities in their region, thereby increasing the
likelihood that interventions are well targeted and appropriate.
5. Strengthen the whole-of-government approach and HEHA Strategy support for
wider environmental change. This will assist in ensuring that approaches are
likely to align well with Māori health frameworks.
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4. HEHA Strategy Evaluation: the views of Pacific Policy-makers
a. Introduction
This section presents the views of the Pacific policymakers about the HEHA Strategy for
the Pacific Health component of the HEHA Strategy Evaluation. Here, we present the
findings relevant to Pacific policymakers from interviews undertaken with a sample of
ten policy makers from different health organisations. Data from semi-structured
interviews were analysed according to the four key evaluation research questions in
order to draw out policymakers’ views on the likely effectiveness of the HEHA Strategy
for the Pacific population.
The overall evaluation questions have informed the development of the Pacific research
questions in order to make the link between the key questions and the Pacific
conceptual framework, Fono Fale health model, which is based on the principles of the
Health and Disability Action Plan (the Action Plan, 2002) (20).
The findings below are presented under each key evaluation question.
b. Methodology
Table 4: Fono Fale model integration in Evaluation
Pacific Health & Disability Action Plan
Principles
Roof: Policy makers, Church & Community Leaders
Posts are Pillars/Pathways: 5 Ottawa Charter Principles
Pathway
Pathway 2
Pathway 3
1
Build
Create
Strengthen
healthy
supportive
community
public
environments action
policy
Dignity &
Sacredness
Active
Participation
Successful
services &
Leadership
Excellent
health
Workforce
Development
Pathway 4
Develop
personal
skills
Pathway
5
Re-orient
health
services
FOUNDATION: Pacific Family or Church parishioners or Community
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The overall evaluation questions were linked into a Pacific interview schedule which
also incorporated the principles of the Pacific Health and Disability Action Plan, Fono
Fale health model and the five pathways of the Ottawa Charter (see Table 4). Three
interview schedules were thereby developed to reflect the roles of Pacific people in
different areas of policy and implementation.
The interviews with policymakers were conducted in January and February. A total of
10 interviews were conducted with Pacific policymakers.
Selection of Key Informants
Key informants were selected in terms of their roles and/or involvement with HEHA in
Government and Non Government Organisations, and some District Health Boards.
Because the sample in this study is small, it is not possible to reveal the organisations
and roles of Pacific people involved in this evaluation in order to maintain
confidentiality.
Interview Process
The 10 policymakers were contacted by a Pacific researcher through telephone calls
and/or by emails. All the interviews were conducted on a one-to-one, face-to-face, basis
although two of the interviews were conducted with two interviewers present.
Interviews were tape-recorded and transcribed verbatim.
Analysis
Each interview was categorised according to the policy area (for example, policymakers
in Government and Non Government Organisations, and those involved in the Planning
and Funding of Pacific Programmes through District Health Boards. The rationale for
this is to identify the perspectives of policymakers working in different policy sectors
and at different levels within the health system. Transcripts were analysed thematically
against the interview schedules, to draw out the key messages and themes. Analyses
also identified additional themes inductively. The messages which emerged from the
analyses were considered under the four areas of the main evaluation questions as
follows: Implementation focus; Outcome focus; Improvement focus; and Funding and
economic evaluation foci. The themes were then linked into the Fono Fale Model to
ensure that the principles of the Pacific Health and Disability Action Plan were
incorporated into the analyses.
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c. Results
1. Implementation focus

How has the HEHA Strategy been implemented?
Role of Pacific Policymakers
Although all the ten Pacific policymakers interviewed work at different policy levels,
their main role is strategic; to ensure that there is a Pacific policy perspective brought to
bear in the development of HEHA and the Implementation plan and that resources are
in place to support Pacific workforce and community development in order to deliver
HEHA programmes.
Key informants interviewed from DHBs held various positions from Pacific General
Managers to overseeing the Planning and Funding for Pacific programmes in HEHA.
Most were actively involved at a policy level with the Ministry of Health, and all were
involved with engaging stakeholders and community leaders who were implementing
programmes.
Engagement of Policymakers and Pacific Stakeholders in the Strategy
Pacific policymakers at Government Departments reported that they were not
consulted or involved with the development of the HEHA Strategy in its early stages.
Work on HEHA was seen to have begun in 2003/2004 and it appears that the Pacific
view may not have been strongly incorporated into HEHA development at the time. It
was noted that as a priority population there should have been greater and more
engagement earlier on. However, as the Strategy progressed, the HEHA team began to
engage with Pacific policymakers from late 2006 when a Pacific policy analyst was
recruited into the HEHA team. This was then followed by the establishment of the
Pacific caucus as an advisory body. The Pacific caucus was reported to have changed the
dynamics of engagement, despite the fact that they were brought in quite late in the
HEHA process. The Pacific caucus members represent clinicians, researchers, managers
and community leaders, and they report that they had a lot of input into the
Implementation Plan.
With the appointment of a HEHA Target Champion in 2007 who is Pacific, a stronger
link emerged between the HEHA team and other Pacific policymakers within the
Ministry of Health and the community i.e. Pacific providers and DHBs. The role of the
Target Champion is a national role to work with the general health sector and the
community in achieving 10 national Health Targets (49).
Furthermore, engagement with Pacific stakeholders was strengthened through the
HEHA Community Action project, in which a lot of engagement was reported to be
happening at all levels of the health system. For example, Pacific people from service
providers, DHBs, community groups, NGOs and researchers were invited to attend a
national workshop to discuss strategies about how best to use the Community Action
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funding to meet the needs of the Pacific communities. The project was the first of its
type where money was seen to be specifically targeted towards Pacific communities.

Has the implementation of the Strategy incorporated the principles of the
Pacific Health and Disability Action Plan (PHDAP)?
There are various opinions about whether the principles of the Pacific Health and
Disability Action Plan (PHDAP) were incorporated into the Strategy during the
development stage. At the implementation stage from a policy perspective, the PHDAP
is written into contracts as a reference guide for DHBs and providers to refer to when
developing their services for the Pacific communities. For example, some principles
such as leadership are included in contracts between the Ministry of Health and DHBs,
with specifications attached to contracts to ensure Pacific governance is adhered to.
On the other hand, the majority of DHB key informants felt they were implementing
principals from Ottawa Charter more than PHDAP. Although one DHB key informant
noted they were ‘interlinked’. The main reason for not using the PHDAP was due to the
fact it was under review so they were using other health frameworks but mainly the
Ottawa Charter.

Provider and workforce development - How was this addressed in the
Strategy?
The views on workforce development are diverse and it appears that the
implementation plan was not seen to appropriately consider the principles of
community development and targeted action. Some policymakers have a strong view
that there needs to be a stronger link back to key priority areas where there is
workforce development money and scholarships, given that nutrition, physical activity,
and obesity is one of the highest priorities for Pacific.
One interviewee noted that there was funding set aside for workforce development and
the focus was not on the whole HEHA workforce. Rather, the focus was on Māori and
Pacific community workers in order to up-skill them with the knowledge in nutrition
and physical activity. Furthermore, the workforce component was incorporated into the
Community Action Project through Crown Funding Agreements with DHBs in which
they had to allocate at least 15% to 25% of their total funding towards workforce
development for their community workers. The same interviewee reported that
workforce development funding was used to fund community workers undertaking
training in nutrition in order for them to teach the community:
“It was a buy-in thing, communities react better to a leader, someone of their own
teaching them, whether it be undertaking a physical activity class or a nutrition
class, the idea was the communities identify someone they wanted trained in
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nutrition or physical activity. That person went out and did some accredited
training and they went back into the communities. The trainer is someone that the
community chose to be trained as a physical trainer or doing a certificate in
nutrition or both.”
Both policymakers and DHB key informants felt that opportunities to sustain workforce
development were being missed. One policymaker felt “one off dietary sessions” held in
church or community environments was an ideal time to encourage participants to
explore career possibilities in nutrition or health education.

Leadership - Has implementation aligned with the integral roles of Pacific
leadership and Pacific communities? Was Pacific leadership appropriately
engaged?
All policymakers saw the Ministry of Health as being the overall leaders of the HEHA
Strategy. However, some participants felt that leadership also comes from Pacific
leaders being involved with decision-making at the strategic level. A good example of
this is the involvement of Pacific representatives in the Steering Sector Group and the
Pacific caucus. Leadership in this sense was enhanced by having Pacific policymakers
within the Ministry and the HEHA team to provide Pacific advice to the HEHA group and
to strengthen engagement with Pacific communities.
This view was also shared by those from Government Departments and DHBs. They saw
the Ministry of Health in a role of overarching leadership where they set policies,
developed strategies and provided funding. Some also felt the Ministry were also there
to provide resources and advise to help them implement the Strategy. One view from a
policymaker was the Ministry was there to provide a link between them and the DHB
and to hold them accountable with what was happening on the ground level.
From a DHB perspective, most felt leadership needed to come from all levels when it
came to the Strategy. However, most felt the important leadership needed to come from
the community. In order to get the ‘buy in’ with the communities, many felt engagement
with community leaders was crucial but this process required good leaders from those
who develop the Strategy to those who implement it.
Overall, most Pacific policymakers saw leadership occurring in different layers or levels
from a top-down and bottom-up approach. Some Pacific policymakers felt that
leadership also comes from the community such as community leaders and church
ministers. There appears to be a view that when the HEHA team engaged with the
community through the Community Action Project, it was successful because the HEHA
team involved the community leaders and DHBs in the planning as they consider them a
key to the success of the implementation. For example, the Lotu Moui programme in
Auckland involved a lot of churches and there is a perception that church members tend
to listen to the church ministers more than to other workers. As a result, it was felt that
if you want to get a HEHA message across the community, policymakers suggested that
you need to go through the church minister/s and he/they will relay the message to
church members and people will listen to him/them:
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“I guess effecting change from a population level, you can talk to people on an
individual level, but if you get a minister on board he can just mention a couple of
minutes after his sermon, “no more fizzy drinks and what-not”- everybody listens to
the minister.”
In some instances, policymakers have found a lot of churches have policies that ‘there
should be no fizzy drink’ and now have healthier food for lunches. In this sense, it seems
that involving the right people who are leaders can effect change. Some interviewees
were careful to note, however, that this is not to say that this change was due to HEHA,
as a lot of work happened before HEHA, but perhaps a little bit was due to HEHA.
As Pacific leadership progresses, there are positive things that are being seen to come
out of engaging with Pacific communities. Some policymakers thought that although
engagement with Pacific was slow, Pacific communities gained a lot from HEHA
initiatives. Particularly, the Community Action initiative fund was seen to be really
critical because it is seen to be a resource to mobilise action across sectors.

Collaboration, co-ordination networks and partnerships across
stakeholders - In what ways did the Ministry of Health engage and partner
with the Pacific Community?
Some Pacific policymakers suggested that the key to collaboration and co-ordination is
for the HEHA team to work closely with the DHB project managers as well as the Pacific
managers to manage the Crown funding agreement.
Collaboration was seen as an important aspect when it came to the success of the
Strategy. All the DHB key informants felt it was important to work not only with the
Pacific community but also with partners like Ministry of Education, NGOs and Local
Councils to be able to provide services to the communities. Most of the DHB key
informants noted that they built on existing relationships as well as forming new ones.
One DHB key informant felt there was not much collaboration happening between the
sectors but felt this was part of their responsibility to start forming these links. They
each gave examples of the amount of time and effort on their part that went into this
process:
“Very important, especially with community work, with anything, with community
work, you know what our people are like, it goes across to anyone (sic). It takes a
while to build relationships, and once you break those relationships it is hard to get
them going again. Collaboration work and understanding between us is important
before we get out to the communities as well.”
Another avenue for co-ordination is the HEHA network which is a web-based network
which was launched at the end 2008. The purpose of the network is to strengthen coordination and collaboration nationally in order for organisations to find out what is
happening with HEHA in other regions.
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
What were some of the challenges when it came to collaboration between
the MOH and Pacific Communities?
Some policymakers felt that there is an assumption by some of the Ministry staff that
the Pacific communities will do the Ministry work for free and give up their free time to
attend advisory meetings such as HEHA. There is a feeling that this assumption by the
Ministry can cause some tension for Pacific policymakers because Pacific policymakers
felt that they need to protect the Pacific communities by compensating them for their
time if they provide advice for the Ministry.
There are also instances in which the Pacific policymakers felt that Pacific is only an
add-on when it comes to collaboration. This is because the Ministry only called upon
using Pacific peoples’ expertise at the last minute when in fact the Ministry will get
credit if the collaboration is done in an appropriate way.
On the other hand, some Pacific policymakers felt that this is a difficult question to
answer as the HEHA team communicates with the Pacific communities through DHBs.
One policymaker reported that the HEHA team found out that there was no relationship
between some of the DHBs and communities and the HEHA team felt that this was a
huge hurdle for HEHA to be a success. In this instance “We really put the onus on DHBs to
engage with the Pacific communities and get the communities to tell them what needs to
be done, instead of the other way around…and we have addressed a lot of that with the
Community Action projects.”
While collaboration is seen to be beneficial when it is done properly, key informants
suggested that it could also result in extra work on the DHBs part to manage relations.
Although interest groups were seen to come together for a good cause they all still have
different agendas which require good management. Overall, they felt the effort put into
forming relations was valuable.

What were some of the positives that came out of the collaboration?
Some key informants noted that the positives are enhanced when there is willingness
from the Ministry staff to engage earlier with Pacific policymakers…“we tell Ministry
staff you would just find your job easier if you engage with us we are not trying to block
the way you do things we would make it easier for you but engage with us.”
Likewise, one policymaker worked with stakeholders to provide training sessions for
community groups on skills in budgeting and project management. As a result,
community members were seen to be given skills which will benefit them outside of
HEHA.
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
Were relationships forged that went beyond consultation which were built
and maintained in ways that were ethical for Pacific communities?
From Pacific policymakers’ perspectives, some felt that at times it was more than
collaboration. Some Pacific central agency policymakers reported that they do not deal
directly with the Pacific communities because they expect the DHBs to build
relationships with the Pacific. However, there were times that some Pacific
policymakers went out of their way and in their own time to engage with the Pacific
community, particularly, on the weekends when Pacific church activities were held. In
this capacity, when the policymakers attended Pacific events, they do not actually
consult with the community but they are there to help the communities increasing their
knowledge about healthy eating and healthy action.

Has engagement with Pacific communities and stakeholders taken into
account the beliefs and values of Pacific peoples with regard to their health
needs?
Some key informants reported that engagement with Pacific communities resulted in
considering the beliefs and values of Pacific peoples with regard to their health needs
through programmes in healthy eating healthy action, in particular, the Community
Action funding which supports training of the workforce, the involvement of Pacific
leaders in the Wider Reference Group and the Pacific caucus group, and having Pacific
policymakers in the Ministry and the HEHA team to provide Pacific advice in regard to
Pacific health needs.
All DHB key informants worked in collaboration with leaders or representatives from
community groups during development stages of programmes. Each programme was
adapted to the beliefs and values of the target groups. For example, engagement for
Church-based programmes involved consultation with Ministers or church leaders.
Other examples included consulting mothers for breast feeding programmes or youth
when it came to engaging adolescents particularly Pacific people who do not affiliate
with a religion.
“Now the churches are not necessarily good magnets for youth and so from that
perspective what can we do to encourage youth into the HEHA regime. And so
again we talk to youth services outside of the churches to be able to engage with
youth HEHA strategy and initiative.”

What sorts of policies, approaches and initiatives worked best and why?
What did not work so well and why?
According to some policymakers, they reported that the community action approach
works really well with Pacific communities. “We know from international evidence that
community development does work”. This is because the community are thereby
empowered to come up with ideas or a programme that works for them. For example,
community gardening, group walks, and some churches have smoke free policies and
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there is a feeling from policymakers that all these approaches have helped raise the
profile of HEHA in local communities.
2. Outcome focus

What changes have taken place for Pacific peoples in terms of awareness in
nutrition and physical activity?
Pacific policymakers reported that a lot of Pacific people are more aware of healthy
eating and the importance of exercising. They have noticed a lot of changes in healthy
lifestyles when they attend community or church meetings. On these occasions, they
have seen healthy food and fruit being served when the groups have their lunches.
Importantly, they have observed that the food being served did not have a “big can of
pisupo or corned beef and other types of foods that Pacific people used to have.” However,
Pacific policymakers noted that when it comes to big community gatherings or cultural
events such as weddings, funerals and birthdays, they felt that the HEHA message of
healthy eating is difficult to filter through in these situations. This is because they have
seen big feasts being dished out on these occasions. So although the HEHA message has
impacted on smaller gatherings, Pacific policymakers felt that there is still a lot of work
to do to get the healthy message across in big gatherings.
When it comes to exercising, Pacific policymakers reported that they have seen more
Pacific people walking and exercising these days compared to ten years ago when
Pacific people were less likely to exercise. From the Pacific policymakers’ perspectives,
they have found that physical activity has always been easy to influence because people
can always get up and go for a walk. In this instance, from their perspectives, the focus
should be on nutrition as it is a lot harder to change eating behaviour than physical
activity.

What actual changes have taken place in the nutrition and physical activity
environments for Pacific peoples?
There was general agreement among the Pacific policymakers that there are some good
changes happening with Pacific communities in terms of people not having to eat
unhealthy food “…they don’t eat a lot of rubbish food” and they are more proactive in
growing their own vegetables rather than them going to the shop to buy vegetables,
which is very expensive. However, some policymakers suggested that these changes
needed to be sustained as there is still a lack of knowledge with some people when it
comes to the volume of food they eat. For example:
“a couple of years ago we had a big church meeting and there was a nutritionist
and she had a paper plate for demonstrating the size for a serving, and she said
this is the size of the plate, it was all good, and then it got to lunch time and
everybody came out with a big sized plate.”
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In terms of physical activity, one policymaker felt providing the tools and a safe
supportive environment was important as some Pacific people felt a stigma with being
overweight which prevented them from exercising in public.
“A lot of our people in churches go for walks at 3 o’clock in the morning, 4 o’clock
in the morning, 5 o’clock in the morning because it’s dark, because they know
they’re not going to be looked at and laughed at when people see them walking on
the road in the morning and in the afternoon.”
Although one would argue that the above perspective may not be a change in attitudes
to improving physical activity because people exercise in the dark due to stigma of
being overweight, this particular key informant suggests that this is a change in
attitudes to healthy action.

Are Pacific communities supportive of the changes?
There is a strong belief from policymakers that Pacific communities are supportive of
the changes as evident by some people who have stopped smoking and some
policymakers have seen changes in attitudes to weight loss. The policymakers believe
that the Pacific communities have acknowledged the problem of obesity and are
supportive of the changes but it has taken some time to achieve this.
There is a strong feeling among some of the policymakers that there has been a lot of
success in awareness within Pacific communities and they felt that it is important to use
that awareness to do activities that people can relate to “…the funding we have given
them to develop a community garden or hold swimming classes or a walking school bus
and give them T-shirts to design”. In this way, Pacific people will know that there is
something tangible that they can achieve as a buy-in from the community.

How do you know that these outcomes have been achieved?
When this question was asked, it appears that some Pacific policymakers had difficulty
in answering the question. This is because they are saying that there are no current
reports to show that Pacific outcomes have being achieved. In addition, policymakers
are of the opinion that although it is really hard to measure the outcomes now, current
anecdotal information has shown a difference. In this instance, some policymakers have
suggested that monitoring is very important in order to measure outcomes. From some
policymakers perspectives’, they have been told by some DHB managers that they can
report on some successes such as the number of people attending cardiovascular
programmes, but they are unable to report on whether Pacific health outcomes are
being achieved.
Most DHBs are still in the process of having evaluations done so there was no specific
evidence to show their outcomes had been achieved. Some described seeing changes in
people’s attitude towards food particularly when it came to catering community events.
Others based it on participation rates at community events but they were unable to be
specific until the evaluations are completed.
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
Is there evidence of reduction in inequalities for Pacific groups?
Some policymakers are of the opinion that there is some reduction in inequalities for
Pacific groups and they say that there is some evidence to support this view. According
to some policymakers, there is a feeling that there is levelling of the incidence of
diabetes with the programmes in Counties Manukau. However, one of the policymakers
had wondered how this levelling of diabetes could equate into reducing inequalities,
particularly, in his view, “equality is when you see Pacific people enjoying the same health
as everyone” in New Zealand and this is not happening with Pacific communities.
Most DHB key informants felt there wasn’t a reduction in inequalities but most agreed it
was a generational problem so it may take time before reductions are seen in statistics.
One DHB key informant felt their obesity rates had increased but that could be due to
better reporting and increase in public awareness to come forward and receive health
care. Another felt in some areas of health there was a reduction for example MeNZB
programme where immunisation rates for Pacific children improved when the service
was delivered by Pacific people. Furthermore, HEHA was seen as a link into other
services that could help reduce inequalities.
3. Improvement Focus

Overall, what worked best and why in terms of engaging with and
supporting the involvement of Pacific peoples: were policies effective in
making changes in these environments?
Workforce development has been considered by Pacific policymakers as a top priority
for improvement and one of the best ways to achieve engagement and implementation
of programmes for Pacific people. There appears to be some very strong opinions from
some policymakers about the need to increase Pacific workforce capacity in training
Pacific people in nutrition and physical activity. And when the trainers completed their
training, they then train their own communities in order to effect change. There is also a
perception by some policymakers that Pacific people can relate to their own people and
therefore, Pacific people would more likely to take the advice from their own people
because of their ethnicity, they speak the language and have the knowledge of Pacific
culture. This view suggests that this does not necessarily mean that a non-Pacific person
is not appropriate to work with Pacific, but what is required in the workforce are the
right people and people who have the understanding of Pacific cultures to engage with
Pacific communities in order for HEHA messages to get through.
Some policymakers also refer to some programmes that are working well:
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“Workforce and interventions are important…like the Healthy Village Action Zone
(HVAZ) and the Lotu Moui they use the getting together like a sport they (sic) drive
the message.”

Overall, what might have worked better and what changes should be made
to the implementation of the Strategy that are likely to improve the
outcomes for Pacific peoples?
Some policymakers stated that the HEHA team could have increased their own Pacific
workforce capacity given that Pacific is a priority group. Responses from DHBs varied.
One DHB key informant felt money could have been spent more wisely on developing a
workforce. Similar to previous comments it was felt training people out in the
community with long term goals in mind would address workforce issues in the future.
Another DHB key informant felt finding strategies to reach Pacific populations outside
of the church environment would be beneficial. Overall, most felt the Strategy was
working well.

Are there any changes to the HEHA Strategy or its implementation that you
think would help to better achieve its vision and goals for Pacific
communities?
Some policymakers felt that it would be a good idea for HEHA to engage into more
primary health care practice, e.g. the green prescription initiative. One particular
participant said that it would be a good idea for HEHA to think about developing a red
prescription to give people something similar to the green prescription. When someone
goes for a check-up, the doctor would tell her/him:
“Your blood sugar is very high, I’d like to give you a red prescription and I’ll ask you
next time whether you’ve been following some of these instructions. Something like
that so it is more practical for people and it becomes a brand. Something that we
can say ‘look you done really well in the last 6 months you need to continue with
one and 3 don’t worry about 2 and 4.”
One participant noted that there are some challenges in the complexity and
understanding of Pacific as trans-national populations in terms of the mobility of Pacific
people between New Zealand and the Pacific Islands. In particular, the issue of mobility
impacts on a population health focus because some Pacific people live in New Zealand
for half a year and they spend the other half of the year in the islands. There is also an
issue with Pacific New Zealand-born and Pacific Pacific-born people as a result of the
cultural differences. This participant raised an issue of how one would address those
different cultural norms when it comes to nutrition. The speaker commented:
“There was discussion about influencing mutton flaps export to the Pacific and the
important bit about that is not the mutton flaps per-say, because that stuff is
complex and has lots of other realities, but it recognised that approaching Pacific
issues requires understanding of Pacific as a trans-national population.”
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While some policymakers suggested the importance of working across sectors in
achieving the goals, they also noted that one of the things that HEHA did really well was
the school programmes. One participant also said that HEHA could also have done a lot
more work with the Ministry of Pacific Island Affairs (MPIA), and with Pacific leaders in
local councils.
Some policymakers also recognised that there are some ideas in the Strategy that are
not appropriate for Pacific people. For example, social marketing, and this is because
the policymakers are of the opinion that Pacific communities do not engage with social
marketing. Furthermore, policymakers noted that Pacific people do not understand the
social marketing concept.
4. Value for Money

Has the HEHA Strategy and its implementation resulted in value-formoney?
The general view of Pacific policymakers is this is a difficult question because there
hasn’t been a national evaluation of programmes to see if they are effective and produce
value for money. However, one participant thought that there has been some progress
in the national breast feeding campaign, there are pamphlets, resources and articles
that profile what is happening with HEHA and this where value for money is coming
from.

Overall, how do you think the HEHA strategy is working?
Overall, the majority of participants think that HEHA is working in terms of building
workforce capacity, and through HEHA, Pacific policymakers gained a good
understanding of community networks and had improved their engagement with the
health sector. According to the policymakers, the most important thing with HEHA is to
get buy-in from community leaders such as church ministers who could influence
changes at a community level.
And lastly, some participants are of the opinion that funding is crucial for on-going
commitment to Pacific communities if the Ministry wants to see some differences in the
near future so that everyone will eat well, and live well as noted:
“…if you roll back the whole HEHA programme tomorrow, it probably wouldn’t
make that much difference to my family, because we are pretty well educated, we
have access to fresh food, fresh vegetables, but it will make a difference in the
communities where the need is the greatest. That is why we need to empower
people, make sure the information, the critical information of what needs to
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happen is reaching Pacific people that are in the position to drive the policy
changes…”
Conclusions Pacific interviews
There were key themes which emerged from the Pacific interviews - Leadership;
Workforce Development; Monitoring; and Sustainability – and these are discussed
below in relation to some of the principles of the Fono Fale model.
Pacific policymakers see leadership operating at different levels, through both “topdown” and “bottom-up” approaches. The two levels are equal and they complement each
other. From a Pacific perspective, it does not matter where the leader sits, whether it is
in the Ministry, DHB or community, no one is superior to another. Although the leaders
sit in different places, they should share the same goals of ‘reducing obesity, improving
nutrition and increasing physical activity’ for Pacific people. The roof of the Fono Fale
model represents leadership in policy from within the Ministry, DHBs, other
government departments and the Pacific communities. From a leadership perspective,
although Pacific leaders were engaged at a later stage, there appears to be a view from
Pacific policymakers that HEHA is working for Pacific communities due to the changes
that are being seen to have occurred, e.g. people are drinking water instead of fizzy
drinks in some gatherings.
The pillars of the Fono Fale model represent the Pacific workforce in HEHA. From a
Pacific cultural perspective, the pillars represent the skills and knowledge of the Pacific
workforce to deliver HEHA initiatives in order to effect change. The HEHA Strategy has
provided Community Action funding to train Pacific workers in nutrition and physical
activity, and this is seen as a positive contribution from HEHA.
Monitoring incorporates all parts of the Fono Fale model from the roof of the Fono Fale
to the foundation, and including all the pillars. It represents monitoring at all levels of
the health sector.
Policymakers were finding it hard to establish whether Pacific outcomes were achieved
or not as a result of the Strategy. This is because there is a lack in monitoring of
programmes to measure their success. Pacific policymakers have said that they have
seen some changes in Pacific people’s attitudes to nutrition and physical activity,
however, they find it really hard to measure health outcomes as there is only anecdotal
evidence to support this is happening.
The whole Fono Fale model represents sustainability. On-going funding is important to
sustain the workforce in the community so that Pacific communities can continue to do
their exercise, to eat healthily, be able to do their garden and other activities and pass
on this knowledge down to the younger generation so that in the near future there will
be a healthy Pacific nation.
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Summary
-
-
-
Leadership: From a Pacific perspective leadership operates on all levels from
policymakers to community leaders. Early engagement with Pacific leaders
during the development of the Strategy would have been preferred other than
that it was felt Pacific leaders were engaged appropriately during the
Implementation phase.
Workforce: Increasing Pacific workforce capacity in nutrition and physical
activity, including Pacific capacity within the Ministry of Health HEHA project
team was a concern among policymakers and key informants. Other areas for
improvement include greater HEHA linkages with primary health care, with the
Ministry of Pacific Island Affairs, with Pacific leaders in local councils, and with
church ministers who can influence change at a community level.
Monitoring: Most DHBs were in the process of having evaluations done, however,
it was difficult to measure Pacific outcomes or changes in inequality when there
was a lack of evidence.
Sustainability: Funding is crucial for ongoing commitment to Pacific communities
to see some differences in Pacific peoples’ health outcomes in the future.
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Discussion: Implementation HEHA Strategy
The HEHA Strategy and its Implementation Plan represent a high quality,
comprehensive policy initiative aimed at the complex problems of improving nutrition,
increasing physical activity and reducing obesity. The focus on developing an evidencebase, recognition of the need to work across sectors and at national, district and local
levels, and recognition of the many settings in which changes need to occur, suggest a
well-thought through Strategy from a public health perspective. The development of the
Strategy appears to have provided a solid grounding for obtaining resources to support
the Strategy - something that does not always happen in New Zealand. Moreover, the
developers of the Strategy have not fallen into the trap of seeing policy development
and policy implementation as separate activities (50), and they are working hard to link
policy development and implementation together (for example, through on-going
communications between key stakeholders at central and district levels).
In general, it appears that the HEHA Strategy is, overall, being implemented as intended,
as evidenced by the following points:
First, those involved in the Strategy development and implementation appear to be
developing and promoting collaboration and co-ordinated networks and partnerships
across sectors and across stakeholders, although it is clear that there is some way to go
in terms of successfully engaging with some central government agencies, and with
some NGOs. One issue that arises here and in relation to funding (see Section 5: Value
for Money) is the difficulty in successfully engaging where no funding is available to
support people’s time for meetings and further engagement, nor for the development of
local initiatives. The community action projects were seen to help with this at least for
some stakeholders, but there are clearly some agencies (especially at district and local
level) where financial support would be appropriate in recognising participation at
these levels.
Second, there appear to be good attempts to ensure active engagement of priority
populations, although this needs to continue to develop with Māori and Pacific groups.
Engagement with children and families is currently largely focused on education
settings, and lower socio-economic groups are mostly addressed as a sub-set of the
other priority groups.
Third, the Strategy and its implementation focus on developing a learning environment,
through a range of vehicles, but there is a need for good communication and sharing of
information to prevent duplication of activity and ensure effective programmes are
being implemented. Good web-based resources are readily accessible and the
developing on-line HEHA Network will other further information sharing, networking
and co-ordination, although opportunities to do this in person are also valued.
Fourth, the Strategy and its implementation appear to be acceptable to stakeholders,
which is shown by their positive overall view of the implementation process. However,
some NGOs have expressed reservations over funding being allocated through DHBs.
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We have yet to interview key stakeholder groups working with DHBs to obtain their
views on this. Some suggestions for modifying implementation have been made, in
particular around greater flexibility at district level in relation to HEHA and stronger
efforts to bring about environmental changes that make personal behaviour changes
easier.
Fifth, actions are being implemented which address the key, priority areas of change.
The stocktake of initiatives will provide further information on this but some
participants suggest that more could be done in relation to physical activity, and at a
national level in terms of advertising environments. In terms of implementation across
sectors, regions, communities, organisations, whānau and individuals, there are some
concerns over the engagement with key sectors (notably NGOs) and not all DHBs are
seen to be doing as well as others. In our next group of interviews we will look at
community perspectives on this.
Sixth, implementation appears generally to be aligned with the key priorities set out in
the implementation plan. Information from the stocktake of initiatives will be used to
assess this further.
Seventh, key themes which emerged from the Pacific interviews were the importance of
Pacific leadership; need for continuing Pacific workforce development; greater
monitoring of outcomes for the Pacific population; and ensuring the sustainability of
HEHA initiatives (including through on-going funding).
In conclusion, HEHA generally seems to be developing along the lines expected,
although some areas for improvement are identified. There are tensions at times
between the desire for collaboration and its achievement in practice. One of the most
effective collaborations seems to have been Mission-On, where collaboration was
mandated, although there were still some initial difficulties in its outworking. There are
tensions too for DHBs, some of whom feel they are more in a purchaser-provider
relationship with the Ministry of Health rather than in a collaborative one – this reflects
the difficulty the Ministry has with carrying a number of roles within the system,
including encouraging capability and innovation while also monitoring progress and
performance.
Policy development and implementation processes generally need to have a number of
features if they are to be successful. Our key evaluation questions focus on a number of
these, including the need for leadership at all levels, clear goals and objectives, adequate
resourcing including knowledge and skills, agreed goals and objectives across
collaborating organisations, as well as a positive political environment at all levels (51).
This suggests that the implementation of the HEHA implementation plan may well be
successful; however, much will now depend on future decisions around leadership and
funding to continue to support HEHA.
Many stakeholders pointed to the importance of monitoring and evaluation of local
district and national HEHA initiatives for the population generally and for the priority
groups. This poses a challenge, particularly where we need to be able to identify change
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over time for Māori and Pacific groups, and at a district level. Another challenge for the
success of HEHA will be balancing ‘top-down’ and ‘bottom-up’ approaches. Strong
national leadership is identified as important, including assessing new evidence and
ensuring effective actions are being undertaken. Some consistency in implementation
also makes it easier for national and regional organisations who are trying to engage
with multiple DHBs, and it would make it easier for the Ministry of Health to monitor
the accountability of DHBs. On the other hand, some DHB key informants reported
tensions between national directives that did not fit well with their community’s
priorities. As the Strategy places a lot of emphasis on collaboration, it is important that
DHBs are not compromised in their ability to engage effectively with their local partners
and support local priorities.
Strengths and Limitations
The high response rate to requests for interviews gives strength to the findings.
However, in interpreting our findings, it is important to note the context and timing of
our interviews and the nature of the interviewees.
First, the interviews took place between January and March 2009, following the election
of a new government in late 2008. Thus the interviews took place in a context of a high
degree of uncertainty over the future direction of HEHA. This may well have affected the
willingness of key informants to offer negative findings, although we found participants
to be very open during the interviews.
Second, many of those interviewed are working directly on HEHA in key national and
district policy agencies, and therefore may be more likely to support the overall
direction set by HEHA. Later interviews will be undertaken with community
stakeholders, including a wider range of NGOs than are included here, and a key part of
the evaluation will be to compare and contrast their views with those reflected in this
report to date.
Third, while this report provides some early comparisons of the findings of our various
data sources, further comparison and integration of these will continue as the
evaluation progresses.
Recommendations
1. The HEHA Strategy should continue to be implemented nationally with its
current framework, which includes the goals of improving nurtrition, increasing
physical activity and reducing obesity. The current focus on priority population
groups of lower socioeconomic groups, children, young people, families/ whānau
should also continue. At this stage we believe that the risks of any substantial
change in direction of the strategy will outweigh any perceived benefits.
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2. The Strategy should maintain an emphasis on environmental change to facilitate
changes in behaviour. Those who implement HEHA should continue to look for
opportunities to create environmental change to support healthy eating and
physical activity.
3. Focus should be maintained on the importance of nutrition to reduce obesity,
and the current imbalance towards physical activity indicated by the Stocktake
should be addressed.
4. Consideration should be given to allowing the District Health Boards more
flexibility to develop priorities at a local level within an appropriate
accountability framework.
5. Consideration should be given to ensuring the ongoing security of future
Strategy funding, which is key to the continuation of established initiatives, and
maintaining institutional expertise and a culture of improvement.
6. HEHA funding that is specifically targeted for Māori and Pacific people should be
audited to ensure that it is being used to enhance Māori and Pacific access to
HEHA programmes.
7. An increased emphasis on the production of high quality evaluations is required
to enhance the evidence base for initiatives. We recommend evaluations should
be undertaken to develop case studies of food industry initiatives; in addition, all
evaluations should contain information about funding sources and value for
money outcomes.
8. Further population data collection is essential in order to monitor nutrition and
physical activity behaviours and environments, as well as body size. Data from
New Zealand Health and Nutrition Surveys, and the Nutrition and Physical
Activity Survey must be examined in order to assess obesity, physical activity
and nutrition related outcomes.
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Section 2: Population Data
Summary
This chapter outlines some of the key baseline data measures that will be used in
analysis of outcomes relating to body size, physical activity and nutrition in subsequent
reports. Balseline data presented here are generally that of 2002/03 as this period
predates the HEHA Strategy development and implementation. In particular these
baseline measures will be compared with data that will become available from national
surveys and the Nutrition and Physical Activity Survey in the future. Initial observation
from the baseline data shows:
 There has been a significant increase in obesity prevalence among New
Zealand adults since 1989. Obesity prevalence is highest in Māori and Pacific
people, as well those who are most deprived. Time trend data show that the
increasing obesity prevalence may be slowing from 2002/03 to 2006/07.
While the latest results are encouraging, we believe that further data points
are needed before a trend can be demonstrated.
 Physical Activity levels have remained relatively stable in New Zealand over
the past decade, although there are some measurement and comparison
issues. That said, about half of New Zealanders meet the minimum
recommendations for health benefit at any given time. Males are generally
slightly more active than females, Māori and Pacific people are more active
on average than other groups. Self-reported barriers to being active are
dominated by lack of time because of work and family commitments. It is
likely however that more structural environmental barriers do influence
activity levels of adult New Zealanders. No reliable and valid national data on
children's physical activity exist for baseline assessments.
 The 2002/03 NZHS reported that overall 68.6% of adults reported eating an
average of the recommended three or more servings of vegetables per day,
while 54.6% of adults reported eating an average of two or more servings of
fruit each day.
Introduction
Although improving nutrition, increasing physical activity and reducing obesity are seen
as long-term goals, measurement of physical activity and nutrition behaviours is
fundamental to the understanding of the success of the strategy. Without changes in
these behaviours (in the right direction) at the population level, the HEHA strategy is
likely to achieve little in terms of improvement in population health status or reductions
in chronic disease prevalence and burden. An appropriate series of population data sets
is required to measure change, particularly in priority groups (children and young
people, Māori, Pacific people, and the socially disadvantaged). Increased international
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awareness of the importance of good nutrition and exercise, and other international
influences such as the fluctuating price of petrol, means attributing specific changes in
nutrition, exercise up-take and obesity, over the period of the evaluation will be
difficult. The evaluation therefore incorporates monitoring tools rather than
experimental approaches. Long-term goals of improving nutrition, increasing physical
activity and reducing obesity may not necessarily be realised within the timeframe of
evaluation. However, evaluation of HEHA related outcomes will require analysis of
nutrition and physical activity behaviours, as well as body size measurements,
especially as there are no specific HEHA targets relating to these goals.
Methods
A number of existing datasets (see Table 5) have been identified as suitable for
monitoring nutrition, physical activity and obesity in the New Zealand population. The
Consortium has also recommended the development of a quarterly survey that can be
used to understand changes in nutrition and physical activity behaviours, and the
environments that support or militate against these. Although comparison across
different datasets poses statistical and interpretive challenges, especially with respect
to mode of collection, a number of surveys have used the same or very similar survey
questions, which will enhance this process. The Ministry of Health has therefore
undertaken to commission a population based Nutrition and Physical Activity Survey
that will provide regular information to the Consortium and other stakeholders about a
range of food consumption and physical activity behaviours, and environmental factors
affecting food consumption and physical activity in those 15 years and older.
More specifically, the Consortium aims to use the survey to:

Examine New Zealand adults’ consumption of fruit and vegetables, whether
consumption levels are changing over time and across different priority
populations (Māori, Pacific and lower social-economic groups) and
demographics.

Identify environmental factors that enable, inhibit or reinforce food and
nutrition behaviours.

Examine adults’ physical activity and inactivity in different settings and whether
these vary across different priority populations (Māori, Pacific and lower socialeconomic groups) and demographics.

Identify environmental factors that enable, inhibit or reinforce physical activity
undertaken by households or individuals.

Identify enabling, inhibiting or reinforcing physical activity behaviours that
households or individuals engage in.
The approach will include conducting a quarterly survey, with the same respondents
retained for surveys in subsequent years. The data will initially be compared to
baseline results from other nationally representative sample surveys (Table 5)
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Our understanding of nutrition behaviours in children is primarily based on the
Children’s Nutrition Survey conducted by the Ministry of Health in 2002.(52) While this
survey provided the necessary nutrition information on children and youth, there are
no plans to repeat it within the HEHA evaluation time frame. However the Mission-On
evaluation survey commissioned by Sport and Recreation New Zealand (SPARC) has
collected a nationally representative dataset using face-to-face interviews in 2008/09.
This survey examines nutrition and physical activity behaviours, and if available to the
Consortium could be used to monitor children’s nutrition and physical activity patterns.
Table 5: Nationally representative datasets containing information on nutrition, physical activity and body
size
Survey
Agency
Description
New Zealand Health Survey
 1996/1997
 2002/2003
 2006/2007
 2009/2010
Ministry of
Health
Obstacles to Action Survey
Sport and
Recreation New
Zealand (SPARC)
& Cancer Society
of New Zealand
SPARC
Nationally representative
sample of approximately 12
000 adults (and 5 000
children in 2006/7).
Includes oversampling of
Māori and Pacific in order
to gain reliable estimates.
Nationally representative
sample of approximately
8,000 adults aged 16 years
and over.
New Zealand Sport and
Physical Activity Survey
 1997/98
 1998/99
 2000/01
Active New Zealand
2007/8
SPARC
New Zealand Nutrition
Survey
1997
2008/9
Ministry of
Health
Statistics New
Zealand
New Zealand Children’s
Nutrition Survey
2002
Ministry of
Health
Mode of data
collection
Face to face
interviews (computer
assisted)
Direct measurement
of BMI in 2006/7
Postal questionnaire
Nationally representative
sample of approximately
4200 aged 16 years and
over
Face to face interview
Self-reported height
and weight
Nationally representative
sample approximately
4,400 16+ years
Nationally representative
sample
1997-approximately 4,600
aged 15+ years
Face to face
interviews
Nationally representative
sample approximately 3300
aged 5-14 years
Face to face
interviews, direct
measurement of BMI,
and other physical
markers body size.
Blood sample
Face to face
interviews of child
and caregiver, direct
measurement height,
weight and waist.
Data presented below are indicative of baseline values and are descriptive in nature. It
is intended that more detailed data analysis be undertaken once results from the NPAS
and Mission-On evaluation survey become available to the Consortium. Some data are
presented as already published by Health and Disability Intelligence. Other results are
presented as directly from the health survey data provided to the Consortium. Where
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this is the case the survey procedure provided in Stata was used to estimate prevalences
and 95% confidence intervals for the outcomes of interest. Weights allowing for age
standardisation were used.
Baseline Data Results
Results are outlined in three sections: Body Size, Physical Activity and Nutrition:
Body Size
For the purposes of this report, body size measurements will be restricted to Body Mass
Index (BMI). BMI is considered to be an effective method of measuring and monitoring
body size on a population basis. BMI is interpreted according to the cut off points in
Table 6, and are consistent with those currently used by the Ministry of Health’s Health
and Disability Intelligence Unit for interpretation of population health surveys. For a
short period before the 2006/07 NZHS different BMI cut off points were used to classify
overweight and obesity for Māori and Pacific people, and so comparison of prevalence
rates of obesity and overweight can be problematic without taking this into account.
Table 6: International cut-off points for adults aged 18 years and over adapted from WHO 2000(2)
Classification
Underweight
Normal range
Overweight
Obese
BMI (kg/m2)
<18.50
18.50 – 24.99
25.00 – 29.99
≥30
Table 7: Classification of obesity and overweight according to BMI (kg/m 2) used in interpretation of New
Zealand data prior to 2006/07 NZHS (53)
Classification
European and Other
Mäori and Pacific peoples
Overweight
25.0–29.9
26.0–31.9
Obese
 30.0
 32.0
Extreme obesity
 40.0
 40.0
The result of using the same BMI cut points for all ethnicities (and thereby lowering the
cut-point for obesity and overweight for Māori and Pacific people) has led to
substantially higher prevalence of overweight and obesity presented in Ministry of
Health published estimates for Māori and Pacific people in the reanalysed data (see for
example Table 8).
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Table 8: Prevalence of Obesity Māori Adults using ethnic specific and standard BMI cut-points in published
data
Survey
Māori Obesity Prevalence using
ethnic specific BMI cut –points (%,
95% CI)*
Māori Obesity Prevalence
using standard BMI cut –
points (%)**
1997 National Nutrition
Men
27.2 (20.3 , 34.1)
Men
41.0
Survey
Women
27.9 (21.4 , 34.4)
Women
40.4
2002/03 New Zealand Health Men
27.0 (21.9 , 32.1)
Men
42.6
Survey
Women
26.5 (22.2 , 30.8)
Women
41.5
* Published in Ministry of Health. 2004 Tracking the Obesity Epidemic: New Zealand 1977 –
2003, Public Health Intelligence Occasional Bulletin No 24. Wellington: Ministry of Health. P 96.
** Published in Ministry of Health 2008. A Portrait of Health. Key Results of the 2006/07 New
Zealand Health Survey. Wellington, Ministry of Health. P118. (95% Confidence Intervals not
given)
Five nationally representative surveys have been conducted in New Zealand, in which
BMI was measured and are summarized in Table 9. These surveys are considered
reasonably comparable, although some variation in measurement methods and study
design has occurred. (1) Ethnicity was self-identified in all five surveys.
Table 9: Nationally representative surveys where height and weight have been measured
Survey
Year
Age
(years)
Sample size (for BMI)
Total
Mäori
National Diet
Survey
1977
20–64
1,761
106*
Life in New Zealand
1989
15 plus
2,924
202
National Nutrition
Survey
1997
15 plus
4,100
638
New Zealand Health
Survey
2002/03
15 plus
10,813*
3,648
New Zealand Health
Survey
2006/07
15 plus
12,488
3160
* there is generally considered to be insufficient Māori respondents in the 1977 National Diet survey, so
time trend analysis for Māori is restricted to the 1989 to 2003 period.(1)
Data from the 2002/3 New Zealand Health Survey have been used as baseline for this
Evaluation report. BMI (below) has been reanalysed to fit WHO standardised cut-points
in order to be comparable with results from subsequent surveys. Prevalence of obesity
increases with the level of deprivation and is significantly high in the most deprived
(NZDep quintile 5) (see Figure 6Figure 7). There are statistically significant ethnic
disparities in obesity prevalence, with Pacific and Māori men and women being
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significantly more likely to be obese than non-Māori, non-Pacific men and women (see
Figure 8 and Figure 9).
Figure 6 Prevalence of Obesity (Female, age adjusted %) by Deprivation 2002/03 NZHS
125
Figure 7 Prevalence of Obesity (Male, age adjusted %) by Deprivation 2002/03 NZHS
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Figure 8 Prevalence of Obesity (age adjusted %) by Ethnicity 2002/3 NZHS
127
Figure 9 Prevalence of Overweight (age adjusted %) by Ethnicity 2002/3 NZHS
Table 10: Prevalence (%) of Overweight and Obesity by Ethnicity 2002/03 NZHS
Māori Female
Māori Male
Total Māori
Pacific Female
Pacific Male
Total Pacific
Asian Female
Asian Male
Total Asian
European/Other
Female
European/Other
Male
Total
European/Other
Total
Overweight
30.1
32.8
31.4
27.6
32.5
30.1
19.4
23.4
21.3
95% CI
26.0 , 34.5
27.8 , 38.2
28.1 , 34.9
22.4 , 33.5
25.7 , 40.0
25.7 , 34.8
14.7 , 25.2
18.1 , 29.7
17.6 , 25.4
Obesity
38.2
40.5
39.3
56.3
54.0
55.2
7.3
4.7
6.1
95% CI
34.0 , 42.5
35.5 , 45.8
36.0 , 42.7
49.8 , 62.6
46.3 , 61.5
50.1 , 60.1
4.3 , 12.1
2.9 , 7.6
4.1 , 8.8
26.9
25.0 , 28.9
19.8
18.2 , 21.6
42.0
39.6 , 44.3
18.0
16.2 , 19.8
34.4
39.4
32.9 , 36.0
37.4 , 41.5
18.9
21.1
17.7 , 20.2
19.5 , 22.7
128
Table 11: Prevalence (%) of Obesity by Deprivation 2002/03 NZHS
NZDep Quintile 1
NZDep Quintile 2
NZDep Quintile 3
NZDep Quintile 4
NZDep Quintile 5
Total
Female
15.3
19.7
21.4
23.8
32.0
22.5
95% CI
12.6 ,
16.5 ,
18.2 ,
20.7 ,
28.5 ,
21.0 ,
18.4
23.3
25.0
27.2
35.7
24.0
Male
13.6
18.7
22.3
21.2
29.3
21.1
95% CI
10.9 ,
15.4 ,
18.7 ,
18.0 ,
25.5 ,
19.5 ,
16.8
22.6
26.3
24.8
33.4
22.7
Baseline data will be compared with that from the 2006/07 NZHS, the 2008/09 NZ
Nutrition Survey, and that from the Nutrition and Physical Activity Survey. One
limitation of these comparisons will be that height and weight from the Nutrition and
Physical Activity Survey will be gathered by self-report and therefore potentially less
reliable than the measured values of the other national surveys.
Comparison data to date shows that, consistent with other countries, New Zealand has
had a significant increase in prevalence of overweight and obesity since 1977. Data
indicate that there has been a shift in the whole population BMI distribution, with the
median BMI increased 12% from 24.4 to 27.3 kg/m3 from 1977 to 2007. (see Figure
11)
Time trend data show that the increasing obesity prevalence may be slowing from
2002/03 to 2006/07. This possibility has been reflected in several in Ministry of Health
reports. (see (2, 54)) While the latest results are encouraging, we believe that further
data points are needed before a trend can be demonstrated. These will be forthcoming
with the 2008/09 Nutrition Survey and the Nutrition and Physical Activity Survey, and
further analysis will be undertaken for subsequent reports.
129
Figure 10 Prevalence of adult (15+ years of age) obesity 1977 - 2006-07(54, p4)
Notes:




The 1977 and 1989 data, unlike the 1997 and 2003 data, could not be adjusted to reflect the changes to BMI
measurement methods and classifications introduced in 2007. Instead only a simple proportional adjustment has been
made to the overall 1977 and 1989 estimates, so these estimates are not fully comparable to the later estimates.
However, the overall trend pattern is still reliable.
Adult defined as 15+ years of age
Rate per 100, age standardised by the direct method to the WHO World Population
X axis identifies surveys chronologically, but does not impose equal time intervals between surveys.
130
Figure 11: Shift in population BMI distribution, ages 20 - 64, 1977 - 2007(54)
Note: Analysis restricted to 20-64 age group as this was the age range included in the 1977 survey.
Physical Activity
Measurement of physical activity
Population surveys have been used for some years to understand levels of physical
activity in New Zealand. We consider that only the last two NZ Health surveys
(2002/03, 2006/7), The Obstacles to Action survey (2003), and the NZ Sport and
Physical Activity survey (2007/08) used instruments which can be considered useable
for understanding prevalence of sufficient physical activity. This measurement includes
PA accumulated over domains including exercise and leisure-time PA, occupational PA,
transport-related PA, and household work. Assessment of reaching the criterion of
sufficient PA is that an individual would recall accumulating a minimum of 150 minutes
of at least moderate intensity PA (such as brisk walking) with bouts on at least five
separate days in that week. This is a usual international criterion based on the US
Surgeon General’s 1996 recommendation for PA for health benefits. This criterion also
matches NZ’s national physical activity guidelines.
131
The surveys used above all use a form of the NZ Physical Activity questionnaire (NZ
PAQ). Previous surveys such as previous NZ Sport and Physical Activity surveys used
survey tools which did not match these nor incorporate all the PA domains above. As
such, we have been unable to consider these. Even direct comparison between the
surveys we have made below should be treated with some caution, as there are
variations in surveys and administration of those surveys.
Physical Inactivity
There is some merit in understanding the proportion of the population who did not
engage in any form of PA in the previous week. Sometimes this group is called
“sedentary”. We would prefer to call this group “inactive” as sedentary behaviour (long
periods of lying or sitting) is not necessarily the opposite of being active. In fact, there is
emerging evidence for the independent contribution that sedentary behaviour can
make to chronic disease risk.
In any case, the highest risk group is the inactive group in the data we present and how
the size of this group is changing is worth understanding over and above the proportion
Table 12: Time trends in Physical Activity and Inactivity- Health Surveys
Survey
Sufficient
activity Male
NZHS 02/03
56.7 (54.5-58.9)
OTA 03
62.6 (60.9-64.3)
NZHS 06/07
55.1 (53.4-56.9)
NZSPAS 07/08* 52.3
Sufficient
activity Female
48.6 (46.5-50.6)
52.3 (50.9-53.7)
47.9 (46.0-49.8)
44.4
Inactive Male
Inactive Female
10.9 (9.5-12.3)
10.1 (9.1-11.1)
12.2 (11.2-13.2)
10.8
13.6 (12.2-15.1)
12.7 (11.8-13.6)
15.7 (14.5-16.9)
14.5
Time trends
The proportion of the population classified as sufficiently active or inactive by sex by
survey type and date is shown above (see Table 12: Time trends in Physical Activity
and Inactivity- Health Surveys). Despite differences in methodology similar figures have
been obtained over the last several years with no real evidence of changes. While
confidence intervals are not shown, the width of these intervals are larger than any
differences over time for all comparisons other than the male estimate of sufficient
activity for the OTA dataset. These data give the research team some confidence to
judge future changes in PA and inactivity in a continuous survey.
Demographic differences
132
We have chosen to use the data from the 2006/07 New Zealand Health Survey using the
most comparable instrument (NZ PAQ SF face to face) to show the profile of sex, ethnic,
and age differences in achieving sufficient PA and inactivity prevalence.
These patterns are typical of those observed in previous surveys and the more recent
NZSPAS (2008). Males are more active than females and less inactive across almost all
almost all age groups. This difference narrows through mid-life but becomes larger
again in later life. This may be due to differences in mortality although these data do
not allow us to draw this conclusion. There are some ethnic differences in PA and
inactivity with Māori and Pakeha (NZ European) similarly active and Pacific and then
Asian groups showing a higher likelihood of being inactive and a lower probability of
being sufficiently active.
A notable exception for PA classifications is that in the Obstacles to Action survey
(2003) and the more recent NZ Sport and Physical Activity Survey (2007/08) Māori
and Pacific ethnic groups showed similar PA levels but higher inactivity levels than
Pakeha with the Asian group still being the least active and most inactive
Figure 12: Regular physical activity for adults, by age group and gender (unadjusted prevalence) (Source
2006/07 New Zealand Health Survey)
133
Figure 13: Regular physical activity for adults, by ethnic group and gender (age standardised rate ratio)
Barriers and motivators for Physical Activity
An important component of the continuous monitor is to track change in barriers to
physical activity. These barriers and motivators can be both social and environmental.
Some of the questions included in the Nutrition and Physical Activity Survey have been
drawn for the 2003 Obstacles to Action survey. Although this survey was conducted by
mail (self completion), the timing and similarity of the questions to those in the
Nutrition and Physical Activity Survey will make the analysis of similar questions useful.
From a timing perspective, the OTA survey was carried out in 2003 just prior to the
launch of the HEHA implementation plan. The survey was also nationally representative
with oversampling for Māori ,but reportedly had relatively low response rates for Māori
and Pacific people.
The evaluation team also consider that the questions pertaining to participants’
perceptions of social and physical environmental barriers are the only way of
reasonably accessing information about environmental change and its impact on
physical activity.
The data presented below are all drawn for the OTA survey and only quesitons that are
comparable to the PA barriers and motivators questions in the Nutrition and Physical
Activity Survey are included for analysis.
134
Table 13: Barriers and Motivators for Physical Activity (Source 2003 Obstacles to Action Survey )
Barrier Affecting Physical Activity
Population Distribution
1. Lack of time due to work
2. Lack of energy/too tired (lazy)
3. Lack of time
responsibilities
due
to family
4. No one to do physical activities with
135
5. Arthritis or other health problems
6. I worry about my safety
7. Costs too much
8. Facilities (parks, gyms) too hard to
get to
136
9. Others discourage me from being
physically active
The only two factors that have a greater proportion of people perceiving an influence
than those perceiving no influence are lack of time due to work and lack of energy/too
tired. Lack of time due to family responsibilities is the only other factor with more than
20% of the population perceiving an influence.
Table 14: Barriers and Motivators for Physical Activity by Gender (Source 2003 Obstacles to Action Survey )
Male
1. Lack of time due to work (47.6%; 45.9-49.3)
2. Lack of energy/too tired (39.1%; 37.4-40.8)
3. Lack of time due to family responsibilities
(28.1%; 26.6-29.6)
4. Arthritis or other health problems (16.2%;
14.9-17.5)
5. No one to do physical activities with (15.0%;
13.8-16.2)
6. Costs too much (clothes, equipment, etc.)
(13.3%; 12.1-14.5)
7. Facilities (parks, gyms) too hard to get to
(11.9%; 10.8-13.0)
8. I worry about my safety (10.5%; 9.4-11.6)
9. Others discourage me from being physically
active (4.0%; 3.3-4.7)
Female
1. Lack of energy/too tired (48.8%; 47.4-50.2)
2. Lack of time due to work (47.0%; 45.6-48.4)
3. Lack of time due to family responsibilities
(36.7%; 35.4-38.0)
4. No one to do physical activities with (21.3%;
20.2-22.4)
5. I worry about my safety (20.3%; 19.2-21.4)
6. Arthritis or other health problems (19.2%;
18.1-20.3)
7. Costs too much (clothes, equipment, etc.)
(16.9%; 15.9-17.9)
8. Facilities (parks, gyms) too hard to get to
(14.9%; 13.9-15.9)
9. Others discourage me from being physically
active (4.4%; 3.8-5.0)
137
Figure 14: Mean PA Barrier Percent by Gender (Source 2003 Obstacles to Action Survey)
Overall, females perceive more barriers to physical activity than males. The top three
barriers are the same for both sexes, although in a slightly different order.
By Age
Table 15: Barriers and Motivators for Physical Activity by Age (Source 2003 Obstacles to Action Survey)
16-34 years
1. Lack of time due to
work (56.8%; 54.758.9)
2. Lack of energy/too
tired (52.5%; 50.354.7)
3. Lack of time due to
family
responsibilities
(31.6%; 29.6-33.6)
4. No one to do
physical activities
with (23.3%; 21.525.1)
5. Costs too much
(clothes, equipment,
35-49 years
1. Lack of time due to
work (57.2%; 55.359.1)
2. Lack of time due to
family
responsibilities
(48.8%; 46.9-50.7)
3. Lack of energy/too
tired (46.6%; 44.748.5)
4. No one to do
physical activities
with (18.3%; 16.819.8)
5. I worry about my
safety (17.8%; 16.3-
50-64 years
1. Lack of time due to
work (44.4%; 42.446.4)
2. Lack of energy/too
tired (37.4%; 35.439.4)
65+ years
1. Arthritis or other
health problems
(33.4%; 30.8-36.0)
2. Lack of energy/too
tired (30.0%; 27.532.5)
3. Lack of time due to
family
responsibilities
(28.0%; 26.2-29.8)
4. Arthritis or other
health problems
(22.8%; 21.1-24.5)
3. No one to do
physical activities
with (23.3%; 21.025.6)
4. I worry about my
safety (12.6%; 10.814.4)
5. I worry about my
safety (16.9%; 15.4-
5. Lack of time due to
work (11.5%; 9.8-
138
etc.) (17.3%; 15.718.9)
6. Facilities (parks,
gyms) too hard to get
to (14.9%; 13.4-16.4)
19.3)
18.4)
13.2)
7. I worry about my
safety (14.3%; 12.815.8)
6. Costs too much
(clothes, equipment,
etc.) (16.6%; 15.218.0)
7. Arthritis or other
health problems
(15.3%; 13.9-16.7)
6. Lack of time due to
family
responsibilities
(10.1%; 8.5-11.7)
7. Costs too much
(clothes, equipment,
etc.) (9.9%; 8.3-11.5)
8. Arthritis or other
health problems
(9.6%; 8.3-10.9)
9. Others discourage
me from being
physically active
(4.5%; 3.6-5.4)
8. Facilities (parks,
gyms) too hard to get
to (14.5%; 13.1-15.9)
9. Others discourage
me from being
physically active
(3.3%; 2.6-4.0)
6. No one to do
physical activities
with (16.4%; 14.917.9)
7. Costs too much
(clothes, equipment,
etc.) (13.3%; 11.914.7)
8. Facilities (parks,
gyms) too hard to get
to (12.4%; 11.1-13.7)
9. Others discourage
me from being
physically active
(5.3%; 4.4-6.2)
8. Facilities (parks,
gyms) too hard to get
to (9.5%; 7.9-11.1)
9. Others discourage
me from being
physically active
(3.9%; 2.8-5.0)
Figure 15: Mean PA Barrier Percent by Age (Source 2003 Obstacles to Action Survey)
Overall, older adults have fewer perceived barriers to physical activity than those
younger than 49 years. The barrier order is similar for all groups except 65+, who have
a unique barrier order.
By Ethnicity
Table 16: Barriers and Motivators for Physical Activity by Ethnicity (Source 2003 Obstacles to Action Survey)
NZ European
Māori
Pacific Island
Asian
139
1. Lack of time due
to work (45.8%;
44.5-47.1)
1. Lack of time due
to work (48.5%;
44.7-52.3)
2. Lack of
energy/too tired
(43.2%; 41.9-44.5)
3. Lack of time due
to family
responsibilities
(29.6%; 28.4-30.8)
4. Arthritis or other
health problems
(16.8%; 15.8-17.8)
2. Lack of
energy/too tired
(43.0%; 39.2-46.8)
3. Lack of time due
to family
responsibilities
(38.3%; 34.6-42.0)
4. No one to do
physical activities
with (22.9%; 19.726.1)
5. Costs too much
(clothes,
equipment, etc.)
(21.9%; 18.8-26.0)
6. I worry about my
safety (21.0%; 17.924.1)
5. No one to do
physical activities
with (15.8%; 14.916.7)
6. I worry about my
safety (12.8%; 11.913.7)
7. Costs too much
(clothes,
equipment, etc.)
(11.6%; 10.8-12.4)
8. Facilities (parks,
gyms) too hard to
get to (10.8%; 10.011.6)
9. Others
discourage me from
being physically
active (2.6%; 2.23.0)
1. Lack of time due
to family
responsibilities
(48.6%; 41.7-55.5)
2. Lack of
energy/too tired
(47.8%; 40.9-54.7)
3. Lack of time due
to work (47.1%;
40.2-54.0)
1. Lack of time due to
work (59.0%; 53.864.2)
4. Costs too much
(clothes,
equipment, etc.)
(37.5%; 30.8-44.2)
5. I worry about my
safety (36.0%; 29.442.6)
4. No one to do physical
activities with (30.9%;
26.0-35.8)
6. I worry about my
safety (24.0%; 19.528.5)
7. Facilities (parks,
gyms) too hard to
get to (17.8%; 14.920.7)
8. Arthritis or other
health problems
(17.4%; 14.5-20.3)
6. Facilities (parks,
gyms) too hard to
get to (31.4%; 25.037.8)
7. No one to do
physical activities
with (31.2%; 24.837.6)
8. Arthritis or other
health problems
(28.1%; 21.9-34.3)
9. Others
discourage me from
being physically
active (5.7%; 3.97.5)
9. Others
discourage me from
being physically
active (15.7%; 10.720.7)
9. Others discourage me
from being physically
active (11.6%; 8.2-15.0)
2. Lack of energy/too
tired (51.3%; 46.0-56.6)
3. Lack of time due to
family responsibilities
(45.7%; 40.5-50.9)
5. Costs too much
(clothes, equipment,
etc.) (27.7%; 23.0-32.4)
7. Facilities (parks,
gyms) too hard to get to
(23.7%; 19.2-28.2)
8. Arthritis or other
health problems
(19.5%; 15.3-23.7)
140
Figure 16: Mean PA Barrier Percent by Age (Source 2003 Obstacles to Action Survey)
Overall, Pacific Island and Asian groups had more barriers than NZ European and, to a
lesser extent, Māori groups. The top three barriers for the population are the same for
all groups, although in different orders. The remaining secondary factors are organised
in different ways.
141
Availability of Environmental Motivators
Figure 17: Availability of Environmental Motivators for PA (Source 2003 Obstacles to ActionSurvey)
Most of the environmental motivators for physical activity are available to the
population, particularly parks, pool/beach/lake, and netball/tennis courts. Cycle
lanes/paths and walking groups were relatively uncommon.
142
Perceived Environmental Barriers
Figure 18: Perceived environmental barriers to PA (Source 2003 Obstacles to Action Survey)
In general, the population does not place much importance on environmental barriers.
In fact, by far the highest frequency of positive answers came in the ‘None of the above’
category. This suggests that people perceive immediate barriers to themselves (ie time,
energy) but not the indirect environmental causes.
143
Nutrition
The HEHA goal of improving nutrition involves the key population health messages:
 Eat a variety of nutritious foods
 Eat less fatty, salty and sugary foods
 Eat more vegetables and fruits (55)pviii
Changes in nutrition behaviours will be monitored by using data from existing data
sources, and comparing them with data from the Nutrition and Physical Activity Survey.
Existing data sources are summarized in Table 17.
Table 17: Population surveys nutrition data
Survey
1997 National Nutrition
Survey
Frame
Representative sample
of NZ adults (15 years
and over)
Oversampling of Māori
and Pacific
2002/03 New Zealand
Health Survey
Representative sample
of NZ adults.
Oversampling of Māori ,
Pacific and Asian.
2006/07 New Zealand
Health Survey
Representative sample
of NZ adults and
children. Oversampling
of Māori , Pacific and
Asian.
2008/09 New Zealand
Adult Nutrition Survey
Representative sample
of NZ adults (15+ years)
Sample
The total number of
respondents was
4,636, including an
oversampling of NZ
Måori and Pacific
people.
12,929 responses (4369
Māori , 910 Pacific and
1173 Asian peoples
(total response ethnicity
counts)
12,488 adults
(3160 Māori ,1033
Pacific, 1513 Asian and
8593 European) (total
response ethnicity
counts)
Mode
Face to face survey
including 24 hour diet
recall, Food frequency
questionnaire, Physical
measurements and
blood sample.
Face to face computer
assisted questionnaire.
Some physical
measurements.
Yet to be finalised.
Approximately 5000
adults.
Computer assisted face
to face survey including
24 hour diet recall,
Dietary habits
questionnaire, Physical
measurements and
blood sample.
Face to face computer
assisted questionnaire.
Some physical
measurements.
Questions about fruit and vegetable intake are included in 2002/3 and 2006/07 NZHS.
More detailed information about nutrition is available from 1997 New Zealand nutrition
survey. Baseline data for HEHA is taken from 1997 nutrition survey and 2002/3 NZHS.
Time trend data is also shown to the 2006/7 NZHS.
The mode of data collection for both the NZHS and the NZ Nutrition Survey is by face-toface interview. Although the current mode of survey for the Nutrition and Physical
Activity Survey is face to face recruitment followed by computer assisted telephone
(CATI) survey instrument, we believe results will be comparable as the wording of the
questions is consistent across survey instruments. However, even though the survey
144
respondents are believed to be representative of the population, comparison of data
across different survey instruments and mode of data collection may bias results, and is
a potential limitation to the evaluation outcomes analysis. Another potential limitation
to data analysis is that all information is gathered by self-report, so results may be
affected by bias. Changes in reported behaviour may indicate that responders are more
aware of what they are supposed to be eating (social desirability) rather than actual
changes in nutrition behaviour.
Fruit and vegetable intake
Consumption of vegetables and fruit is associated with a range of positive health
outcomes, including decreased risk of obesity, cardiovascular disease and some
cancers.(55, 56)New Zealand guidelines recommend that adults consume at least three
servings of vegetables and two servings of fruit per day. (55) Data pertaining to intake
of fruit and vegetables by New Zealand adults comes from three sources: the 1997 Adult
Nutrition Survey, and the 2002/03 and 2006/07 New Zealand Health Surveys. It is
usually reported as prevalence of adequate fruit and vegetable intake as defined in the
current dietary recommendations from Ministry of Health. (55)
145
Baseline data: 2002/3 New Zealand Health Survey
The 2002/03 NZHS coincides most closely with the development of the HEHA strategy,
and therefore forms the timeliest data for the baseline data set.
The 2002/03 NZHS reported that overall 68.6% (95% Confidence Interval 67.0 , 70.1)
of adults reported eating an average of three or more servings of vegetables per day,
with females significantly more likely to report this (71.1%) than males (63.3%). Ethnic
differences are shown in Figure 19, and show that for males, European/Other and Māori
were significantly more likely than Pacific and Asian men to report eating an average of
three or more servings of vegetables each day. For females, European/Other were
significantly more likely than all other ethnic groups, and Māori were significantly more
likely than Pacific and Asian women to report eating an average of three or more
servings of vegetables per day.
In both males and females, the proportion of adults who reported eating an average of
three or more servings of vegetables each day increased with age (see Figure 21).
In both males and females, the proportion of adults who reported eating an average of
three or more servings of vegetables per day was higher in NZDep2001 quintile 1 than
in quintile 5 although the difference was significant only for females (see Figure 20).
Figure 19: Vegetable intake (three or more servings per day) in adults, by ethnic group and sex (age
standardised) Source: 2002/03 NZHS (53)
146
Figure 20: Vegetable intake (three or more servings per day) in adults, by NZDep2001 quintile and sex (agestandardised). Source 2002/03 NZHS (53)
Figure 21: Vegetable intake (three or more servings per day) in adults, by age group and sex. Source
2002/03 NZHS (53)
Fruit intake
Overall, 54.6% of adults (53.3, 55.9) reported eating an average of two or more servings
of fruit each day, with females significantly more likely (63.6%) than males (43.3%) to
report two or more servings per day. Ethnic differences in reported fruit consumption
are summarized in Figure 22. In both females and males, the proportion of adults who
147
reported eating an average of two or more servings of fruit each day increased with age
(see Figure 24). Females in NZDep2001 quintile 1 reported eating significantly more
fruit than females in quintile 5, although for males there was no significant difference
across the quintiles (see Figure 23).
Figure 22: Fruit intake (two or more servings per day) in adults, by ethnic group and sex (age standardised).
Source 2002/3 NZHS(53)
Figure 23: Fruit intake (two or more servings per day) in adults, by NZDep2001 quintile and sex (age
standardised). Source 2002/03 NZHS(53)
148
Figure 24: Fruit intake (two or more servings per day) in adults, by age group and sex. Source 2002/3 NZHS
(53)
Time trend data
Time trend data to date examines results from the 1997 National Nutrition Survey and
the 2002/03 and 2006/07 New Zealand Health Surveys. There was a significant decline
in proportion of men who consumed three or more servings of vegetables per day
between 2002/3 and 2006/07 NZ Health Surveys. For women there was a significant
decline between 1997 NZ Nutrition survey and the 2006/07 NZHS results but no
significant change between 2002/03 and 2006/07.(see Figure 25).
149
Figure 25: Adequate vegetable intake for adults, by gender, 1997, 2002/03 and 2006/07 (age standardised
prevalence) (2)
For Māori there was a significant decline in proportion of men who consumed three or
more servings of vegetables per day (adjusted for age) between 2002/3 and 2006/07
NZ Health Surveys. For Māori women there was no significant difference in the
proportion who consumed three or more servings per day since 1997 adjusted for age.
There has been a significant increase in the proportion of men and women who have
two or more servings of fruit per day (adjusted for age) since 1997. There is a similar
increase for Māori (data not shown).
Time trends for proportion will be continued by ethnicity (Māori , Pacific, Asian, NZ
European, Other ) across: 1997 NZ Nutrition Survey, 2002/03 NZHS, 2006/7 NZHS,
2008/09 NZ Nutrition Survey and Nutrition and Physical Activity Survey results.
150
Figure 26: Adequate vegetable intake for Māori adults, by gender, 1997, 2002/3, 2006/7 (age standardised
prevalence) (9)
151
Figure 27: Adequate fruit intake for adults, by gender, 1997, 2002/03 and 2006/07 (age standardised
prevalence) (2)
152
1997 Nutrition Survey
Detailed information about adult nutrition comes from the 1997 New Zealand Nutrition
Survey. The 2008/09 New Zealand Nutrition Survey is currently in the field. A number
of questions from the 1997 and 2008/09 Nutrition Surveys are also contained in the
Nutrition and Physical Activity Survey and will be compared. In particular, we are
interested in data about fruit and vegetable intake, and intake of food that is high in fat,
salt and sugar (such as sugary drinks). Data will be analysed by age, gender, ethnicity,
and NZDep where appropriate.
.
153
Section 3: Stocktake of HEHA Initiatives
Summary
A comprehensive stocktake of all national, regional, and local HEHA and HEHA-related
initiatives was undertaken. In total we captured over 1200 initiatives currently
underway. At present this database capture the types of activities and how they relate
to HEHA priorities. As the database is updated over the next three years, tracking of
changes in programs, types of initiatives, and the balance between physical activity and
nutrition programmes will be undertaken.
Interesting findings we have drawn from the stocktake to date are:
 There are a large number of initiatives across the country at local levels.
 There are several strong nationally-led programmes in place
 On balance physical activity programmes outnumber nutrition programmes. The
number of public parties external to the health system (e.g., city and regional
councils, sporting organisations) is much larger for the provision of sporting and
physical activity opportunities so this result shouldn’t be surprising.
 Coverage for priority groups is excellent for Māori and Pacific, but Asian and
South Asian coverage is low
 Settings approaches to HEHA are starting to take effect. School-based and
primary-care settings approaches are well established, while workplaces,
churches, and marae based settings are becoming established.
 Overall there is an emphasis within programmes to cover multiple levels of the
socio-ecological framework (classified according to Ottawa Charter outcomes
(see Table 21) needed to sustained behaviour change. This is very important and
shows a move beyond simply educating and getting messages about eating and
exercise. This approach is strength of the collective initiatives across the sectors
involved in HEHA.
 Very few of the initiatives have evaluation components attached to them.
Evaluation should be regarded as an essential part of the practice of evidencebased health promotion. Outcome evaluation (behaviour and health change) is
critical to justify continued investment from the government and health sector.
While outcome evaluation is important, formative, and process evaluations are
critical in this area to ensure a continuous improvement model in programme
delivery.
The stocktake of initiatives was limited in several aspects of data collection. These
relate mainly to our ability to only capture data from either existing databases or by
self-report by those who sent back information to us. This meant that we were unable to
gather data on programme quality, and it is likely that there are programmes which we
have not been able to capture because information about them was not available from
existing sources, and/or agency self-audit and follow up was not forthcoming. That
aside, the audit and follow up process was intensive and likely captured the all national
154
and the bulk of regional activity. For local activities we cannot determine how much
programme activity we missed. There were many missing fields in programme selfassessment and database audit in developing our new database. Of particular note is
that we were only able to gather data on investment (money spent on programme) for
around half the programmes. This, combined with the lack of evaluation, has limited our
ability to assess programme quality.
Introduction
In assessing the success of the HEHA strategy, it was important to first undertake a
stocktake of HEHA-related initiatives across New Zealand to answer questions about
health impact and value for money. The database serves as a valuable tool in
determining the type of activities taking place at national, regional and local levels, and
identifying existing gaps, areas of focus and programme evaluations. Without this
information, educated decisions about the strategy will be difficult. Notwithstanding the
importance of this tool, programme stocktake is a dynamic process, which requires
constant maintenance, meticulous information gathering and entry and a systematic
approach to quality assurance. The database been designed to track progress for future
evaluations.
Methods
An Access database was developed to capture information from current initiatives and
their outcomes. The identification of field codes has been a work in progress since early
2008 and finalised late 2008 following feedback from the Ministry of Health HEHA
Strategy Evaluation Team. The database was built to capture information from
initiatives:

Relevant to the HEHA Strategy

With an economic evaluation

Relevant to Food Industry Group
To best capture information, field codes were assigned under the groupings of: General
Programme Details, Programme Outcomes, Physical Activity Environment Outcomes,
Nutrition Environment Outcomes, Obesity Environment Outcomes, Breastfeeding
Environment Outcomes, Programme Targets, Programme Type (Physical Activity,
Nutrition, Obesity, Breastfeeding), Programme Setting, Programme Target Population,
Funding Duration and Total, Programme Funding Sources, Outcome Evaluation
(Nutrition, Physical Activity, Obesity, Breastfeeding, Priority Groups), Programme
Recommendations, Economic Evaluation Progress Reports, Economic Evaluation
Programme Expenditure, Economic Evaluations Programme Resources, and Economic
Evaluation Summary.
155
A full list of field codes is provided in Appendix 4. The electronic Access database is
supplied as part of this report on disk (Appendix 7).
A secondary database was also developed specifically for the Food Industry Group
initiatives using the following groupings: General Details, Targets, Policy, Relationships,
Outcomes, Evaluation and Recommendations.
The principle sources of data were:

2007/2008 Ministry Approved Plans (MAP)

Agencies for Nutrition Action (ANA) Database

Primary Health Care Implementation Work Plan

Health Research Council

PANnet (a web based information network for providers working to improve
Aucklanders' nutrition and levels of physical activity.)
Quality Assurance
Data entry from the ANA database and the remaining sources involved cross
referencing against the MAP database to reduce repetition of initiatives. Several
initiatives throughout the MAP database were repeated with very minor discrepancies
between each. Where possible every effort was made to identify and delete repetitions
throughout the database. Repetition may have occurred where a initiative had appeared
in more than one database under two different names. The reporting process
highlighted several small inconsistencies throughout the database and provided a base
to quality assurance procedures. Initially, two staff members were designated to
alternate sections of the database to check. They were given the initiatives on which
they had not completed the original data entry and were instructed to check that all
relevant fields had been completed to the level of knowledge received. This process was
repeated for several initiatives following initial reporting rounds.
Inclusion and Exclusion Criteria
The majority of physical activity and nutrition, breastfeeding and obesity initiatives
from the MAP database were included. A small number of initiatives were excluded if
the outcomes indicated health based targets that did not involve physical activity or
nutrition; however, the number was very small. Initiatives listed which were no longer
being implemented, with very little or no funding were also excluded. The same criteria
were used for the ANA database.
156
HEHA and Non HEHA initiatives
The decision to code an initiative as HEHA or NON-HEHA funded was made by
presuming that all initiatives listed in the MAP database were HEHA funded unless
otherwise stated. A cross check against the MAP reporting documents was undertaken,
which confirmed that this was correct in most cases. This cross check highlighted that
there were several non HEHA funded initiatives listed in the word document, and not
included in the actual database. These were essentially Council funded initiatives
around development of parks, walkways, and cycle paths, with outcomes to increase
physical activity opportunities. These initiatives have since been entered into the access
database. Any initiative with no indication as to HEHA or non HEHA funding was coded
as Unknown.
Funding Sources
The MAP database provided information on total funding for the entire time span of the
initiative and not just the period of the report. Where funding amounts and sources
have been given, but no breakdown between sources had been provided, the amount
given was split evenly between the known sources. This prevented any loss of funding
source information in the reporting process.
Missing Information
All funded initiatives from MAPs have been entered in the database. There were
significant gaps in the information provided particularly in the funding details; funding
amounts and funding source. Wherever possible details were researched and accessed
from alternative sources such as project co-ordinators, HEHA Project Managers, and
relevant websites. Overall, there were funding details for approximately 516 initiatives.
The research team is attempting to contact the remaining 750; however, it was not
possible to have this information for the interim report.
Initiative start and finish dates were also not provided in many cases. Where possible
an attempt was made to access this information from alternative sources but have been
unable to capture all timeline details.
Engagement of HEHA Project Managers
HEHA project managers were contacted by phone to explain the purpose of the
database and to request their assistance for future information. The call was followed
up with an email, and a request for any evaluations available. Throughout the data entry
phase of the database, project managers were contacted for any missing information on
initiatives within their region. Where possible relevant information was given or
alternatively they would direct us to the appropriate person.
157
Most managers were happy to help and available evaluations were sent promptly.
These evaluations were cross referenced against database provided by MoH indicating
which evaluations were due. The following evaluation were all due prior to Jan 2009 but
not available at this time: Tongan Community Action Project, Why Weight, Korikori An
Iwi, Evaluation of He Tifa Ola – bilingual Access Radio Programme, Process and Impact
Evaluation of CDHBs HEAL (Healthy Eating Active Living) Project.
Food Industry Group Initiatives
The Food Industry Group section of the stocktake database was designed around the
FIG reporting database template, to ensure that all available information was captured.
The database received was incomplete and it seems that there was no other way to
collect this information.
The AUT team met with Sally Hughes - Senior Analyst – Industry MOH to discuss the
Food Industry Accord and were subsequently directed to Vicki Hamilton – Executive
Director of the Food Industry Group. The team met with Vicki Hamilton to discuss ways
to maximise the amount of information entered into the database on each of the Food
Industry Groups. It was suggested that the access database was not an accurate way of
reporting on FIG policies, as throughout the FIG there were variations in
appropriateness of outcomes.
Concerns were raised on the confidentiality of the FIG reporting database and assurance
has been requested that any information entered into the HEHA Evaluation access
database from the FIG reporting database would not be available to the public. Concerns
were also raised around the merit of assessing the FIG and not assessing the Catering
and Hospitality Association. The usefulness of the FIG database is therefore questioned.
Completion of Database
The majority of data entry was completed by mid March 2009, although funding details
for several nationally funded initiatives were still under investigation.
Results
We have chosen to provide summaries of the initiatives across settings, priority area,
programme type, and so forth. The full database contains the entire detailed list of
initiatives with all relevant fields. Such a database is really useful for generating reports
such as those seen here. Full lists with all fields are just not possible to provide in
printed form, and thus should be accessed through the electronic database supplied.
158
Patterns emerging from the stocktake will be briefly discussed in terms of:

Types of initiatives (Table 18)

Target population groups (Table 19 & Table 20)

Outcomes (Table 21 & Table 22)

Targets (Table 23)

)

Food Industry Group (see Section 5)
Overview
There were 1249 initiatives identified. Initiatives were assigned to three main
categories (Table 1): Initiatives that focused on nutrition (20%); physical activity
(35%); and both (44%). Overall, there were more physical activity initiatives. However,
a focus on the number of initiatives alone does not take into account that initiatives may
have been of quite different scales. The only measure of this was the level of funding
allocated to initiatives. Funding information was available for only 423 (34%) of
initiatives (81 nutrition (19%) initiatives, 114 (27%) physical activity initiatives, and
226 (53%) both); with 23% of funding available to nutrition, 46% to physical activity
and 31% to initiatives which cover both nutrition and physical activity. A higher
proportion of funding was being allocated to physical activity initiatives.
Types of Initiatives
The majority of the initiatives were implemented at the regional level (79%) targeting
both physical activity and nutrition. At the national level there was an almost even
spread of focus between nutrition, physical activity and combined. At the district and
local levels the emphasis was on physical activity than nutrition initiatives.
Table 18: Number of initiatives by type
Total
Nutrition
National
89 (7%)
Regional
995
(79%)
41 (3%)
District
Physical Activity & Nutrition
30
Physical
Activity
35
207
322
466
9
15
17
24
159
Local
129
(10%)
11
70
48
Target population groups
Priority groups. Health inequalities in health outcomes exist between Māori and nonMāori ethnic groups and between Pacific and non-Pacific-non-Māori groups. Most
notably these disparities are seen in the rates of obesity with Māori and Pacific
communities suffering the most. For these reasons reducing health inequalities has
been a key priority for the HEHA strategy and emphasis needed to be placed in
addressing the needs of specific populations.
It is evident from the stocktake that initiatives in all three categories were targeted
primarily on Māori, Pacific, low socioeconomic and Family/Whānau groups. Within this
group greatest focus was placed on initiatives that addressed both nutrition and
physical activity in the Māori population and on nutrition initiatives in Family/Whānau
group. Least emphasis was placed on Migrant, Asian, Chronic Disease and Health
workforce groups.
Table 19: Number of initiatives by target population group: priority groups
Nutrition
Physical
Activity
Physical
Activity&
Nutrition
Total
Māori
Pacific
Migrant
Asian
Low
SES
Family/
Whānau
Chronic
Cond
Health
Work
force
256
121
95
2
5
96
149
6
25
47.3%
37.1%
0.8%
2.0%
37.5%
58.2%
2.3%
9.8%
176
138
4
8
145
191
21
13
40.2%
31.5%
0.9%
1.8%
33.1%
43.6%
4.8%
3.0%
330
240
18
26
217
263
41
36
59.5%
43.2%
3.2%
4.7%
39.1%
47.4%
7.4%
6.5%
438
555
Children, Youth and Adults
The majority of the initiatives in all three categories were targeted primarily at children
(Table 20) with youth receiving the least focus. When initiatives were examined in
terms of targeting specific age groups, those with a nutritional focus were implemented
primarily in the young adult population, those with physical activity focus in middle age
and older adult population and those initiatives that targeted both nutrition and
physical activity had focused on the adult population.
160
Table 20: Number of initiatives by target population group: children, youth and adults
Nutrition
Physical
Activity
Physical
Activity&
Nutrition
Child
Youth
Older
Adults
Age
0-4
Age
5-12
Age
13-18
Age
18-25
Age
26-39
Age
40-59
Age
60+
All
Ages
140
16
3
55
34
55
121
114
75
38
88
54.7%
6.3%
1.2%
21.5%
13.3%
21.5%
47.3%
44.5%
29.3%
14.8%
34.4%
199
37
67
17
104
105
135
139
171
173
137
45.4%
8.4%
15.3%
3.9%
23.7%
24.0%
30.8%
31.7%
39.0%
39.5%
31.3%
256
29
32
46
101
117
165
161
170
137
258
46.1%
5.2%
5.8%
8.3%
18.2%
21.1%
29.7%
29.0%
30.6%
24.7%
46.5%
The stocktake data suggest that overall, priority groups were indeed the focus of the
HEHA Strategy.
Outcomes
More than half of nutrition initiatives were focused on building healthy public policy
and creating supportive environments; some were focused on developing personal
skills and strengthening community action; but only a small proportion of initiatives
were focused on reorienting health services; and far fewer on monitoring, research and
evaluation; communication; workforce development; and sector collaboration.
Table 21: Number of initiatives by outcome (Ottawa Charter)
Table 3a
Total
Nutrition
256
Physical
Activity
438
Physical
Activity&
Nutrition
554
Build
Healthy
Public
Policy
149
Creating
Supportive
Environment
Strength
Community
Action
Developing
Personal
Skills
Reorient
Health
Services
146
63
100
29
58%
57%
25%
39%
11%
120
375
212
85
41
27%
86%
48%
19%
9%
244
405
263
264
134
44%
73%
47%
48%
24%
The vast majority of physical activity initiatives were seen as creating supportive
environments; with almost half focusing on strengthening community action. Some
initiatives focused on building healthy public policy and developing personal skills; very
few focused on other categories of action.
161
Three-quarters of initiatives focusing on both nutrition and physical activity were
creating supportive environments; while almost half of these initiatives focus on
developing personal skills, strengthening community action and building healthy public
policy. Some initiatives were also aimed at reorienting health services (more so than the
initiatives focused on only one goal).
Table 22: Number of initiatives by outcome (Other)
Total
Nutrition
256
Physical
Activity
438
Physical
Activity&
Nutrition
554
Monitor
Research
Evaluate
13
Communication/
Social
Marketing
21
Workforce
Development
12
Strength
Sector
Collaboration
2
5%
8%
5%
1%
19
14
10
4
4%
3%
2%
1%
50
41
46
6
9%
7%
8%
1%
Overall, the focus was on creating supportive environments, strengthening community
action, developing personal skills and building healthy public policy. The key priorities
included in the ‘Start Here’ list in the HEHA Implementation Plan, for district level
organisations (the basis for many of the initiatives in the stocktake database) include
creating supportive environments (especially in education settings), strengthening
community action (especially for high-need groups), reorienting health services,
monitoring and evaluation, and communication5 (8). Thus, the stocktake did show a
particular focus on the first two of these. Few initiatives focused on reorienting health
services; monitoring, research and evaluation; communication; workforce development;
and sector collaboration.
Targets
The majority of the initiatives focused on nutrition targeting healthy eating, and fruit
and vegetable consumption. Very few initiatives focused on decreasing sugary drinks,
energy dense foods, high fat foods, obesity and sedentary behaviour. Stocktake data
suggest that more emphasis may be needed on these specific targets in the future.
5
Building healthy public policy was seen as a Ministry of Health and Industry objective while workforce was seen as an
MoH, NGO and education section objective and these initiatives may not have been as easily identified in the stocktake
dataset.
162
Table 23: Number of initiatives by target outcome
Table 4
Total
Incr.
Fruit&
Vege
Decr.
Sugary
Drinks
Decr.
Energy
Dense
Foods
Decr.
High
Fat
Foods
Decr.
Obesity
Incr.
Healthy
Eating
Nutrition
256
70
16
28
27
29
27.3%
6.3%
10.9%
10.5%
Physical
Activity
438
5
0
0
0
1.1%
0.0%
0.0%
111
13
20.0%
2.3%
Physical
Activity
&
Nutrition
554
Incr.
PA
Incr.
Breast
Feeding
201
Decr.
Sede
ntary
Beha
viour
2
17
81
11.3%
78.5%
0.8%
6.6%
31.6%
47
17
10
434
0
0.0%
10.7%
3.9%
2.3%
99.1%
0.0%
28
29
247
541
20
544
45
5.1%
5.2%
44.6%
97.7%
3.6%
98.2%
8.1%
Settings
School Setting. There seems to be a consistency in initiatives spread across early
childhood, schools and tertiary education settings focusing on nutrition alone (Table
24). Initiatives that focused on physical activity seem to be implemented most
frequently in primary schools, followed by intermediate and secondary schools
compared to the other groupings. Initiatives targeting both physical activity and
nutrition were well represented in primary, intermediate, secondary schools and early
childhood but very poorly in tertiary education settings.
Table 24: Number of initiative by setting: School
Total
Nutrition
256
Physical
Activity
438
Physical
Activity
Nutrition
554
Early
Childhood
25
Primary
School
37
Intermediate
School
32
Secondary
School
34
Tertiary
9.8%
14.5%
12.5%
13.3%
0.4%
29
70
58
53
10
6.6%
16.0%
13.2%
12.1%
2.3%
81
101
91
86
26
14.6%
18.2%
16.4%
15.5%
4.7%
1
&
Community settings. Most of the nutrition initiatives were implemented in primary and
secondary health care. Physical activity initiatives were implemented at the workplace
and initiatives that combine both nutrition and physical activity initiatives were
implemented in primary health care. Overall, very few initiatives were implemented in
health care facilities, rest homes, churches and maraes.
163
Table 25: Number of initiative by setting: community
Nutrition
Physical
Activity
Physical
Activity&
Nutrition
Total
Workpla
ce
Prim
Health
Care
Second
Health
Care
Health
Care
Facilitie
s
Rest
home
Church
Marae
Shop
Centres
Markets
256
26
30
33
21
2
7
12
20
10.2%
11.7%
12.9%
8.2%
0.8%
2.7%
4.7%
7.8%
40
27
7
17
8
15
21
8
9.1%
6.2%
1.6%
3.9%
1.8%
3.4%
4.8%
1.8%
77
102
52
45
17
51
76
18
13.9%
18.4%
9.4%
8.1%
3.1%
9.2%
13.7%
3.2%
438
554
Conclusions
The stocktake of HEHA and HEHA-related initiatives is important in understanding the
overall context and spread of activities at various levels (local, regional, national) and in
various levels of behaviour change (e.g., policy, environmental, personal change, health
sector).
What is clear is that there is a wide range of different of initiatives in place across New
Zealand. Whether the sheer number of the programmes and initiatives dilutes
intervention efficacy is unknown. In other words, there may need to be a balance
between programmes coming from grassroots that are community driven, and
nationally lead initiatives that are evaluated soundly. Our preference is to advise that
there is no substitute for programme and initiatives lead nationally with sound and
credible evaluation built around the initiative. However, these programmes can, and
must have local ownership and flavour for sustainability and success in community
engagement. It is also conceivable, given the number of different programmes, that
there is considerable duplication of resources.
For the future this stocktake will be updated annually. How the breadth and depth of
initiatives change across the domains we are coding for will be very useful, especially as
health policy changes at government level, and we gain more evidence about the
effectiveness of different approaches in changing population levels of healthy eating and
physical activity. We intend to up this stocktake to track these changes at local,
regional, and national level across the range of priority groups, settings, ad levels of
intervention over the next three years.
Note: An electronic version of the database is situated in Appendix 7.
164
Section 4: Review of Food Supply and Environmental Interventions
Introduction
Because the HEHA Strategy has an ecological approach that recognises the importance
of environmental change in supporting healthy lifestyles, the Strategy evaluation
examines how changes to food supply and the wider environment have supported the
Strategy goals. Assessment of food and nutrition environments are increasingly
recognised as an important route to gaining an understanding of obesity prevention
(57) and the analysis of food supply will form an essential component of the Evaluation.
Food supply is influenced by many factors, ranging from macro-level policy decisions
(such as crop subsidies) to micro-level retail decisions (such as brand listing and facings
allocation decisions) (58). An analysis of supply side and environmental interventions
thus requires a review of different sectors, the levels that operate within these, and the
integration of initiatives within and across sectors. In the context of HEHA, an
evaluation of supply side activities should review the products, or foods, available to
consumers, particularly the availability of foods lower in fat, salt and sugar. The
accessibility of these foods, both geographically and economically, also requires
assessment. Finally, the behaviour changes that occur in response to interventions
altering food supply or the salience of particular foods within purchase and
consumption settings should also be assessed.
Four main outcome variables will be monitored:
•
•
•
•
Food supply (a measure of food availability)
Food purchase (a measure of some food purchases and factors, such as
affordability, that affect purchase behaviours)
Food consumption (an estimate of reported consumption and an analysis of the
factors shaping consumption choices)
Food composition (details of food items’ nutritional value)
This interim report contains findings from a review of the Food Industry Group (FIG)
database. Later reports will be extended to include a wider analysis of Food Supply as
other data sources are accessed.
Future reports will thus provide a more
comprehensive overview of food supply. Nevertheless, as an umbrella group for many
of the largest food manufacturers and suppliers in New Zealand, data from the FIG are
critically important as members’ products constitute a substantial proportion of
consumers’ food purchases.6
6
In 2000-2001, sales of fresh milk, butter and cheese, bread, breakfast cereals, biscuits, cakes, buns and pastries, soft drinks
and cordials, confectionery, meals away from home and ready-to-eat foods constituted 56.3% of households’ total food
expenditure. In 2003-04, this figure was 48.8%. Source: 59.
Turley M. Food and Nutrition Monitoring Report
2006: Public Health Intelligence Monitoring Report 9. Wellington: Ministry of Health2006.p25
165
Analysis of the Food Industry Group Database
Background
The Food Industry Group (FIG) was established in late 2005 following the signing of a
Food Industry Accord (FIA) in September 2004. The group was convened to help
ensure that “the intent of the Accord was carried out”. (60)As part of that work, the FIG
has embarked on initiatives with food manufacturers to achieve its overall mission,
which is:
“To do all that is possible to encourage all sectors of the food industry to create
commercially successful products and services that will make a positive
contribution to the health of New Zealanders.”(60)
As well as working with its members, the FIG has also developed a relationship with the
Ministry of Health; FIG documents state that: “in developing our goals, [it] has used as a
foundation The Government’s Healthy Eating Health [sic] Action plan 2004 – 2010.”(61)
To document the work its members have undertaken, the FIG has maintained a
database outlining initiatives developed in response to the growing prevalence of
obesity. This database was made available to the HEHA Consortium so that FIG
members’ initiatives could be examined and further research questions and data needs
identified. Reviewing food industry actions to change the New Zealand food supply will
help address evaluation questions relating to wider environmental changes that may be
attributable to or linked with the HEHA Strategy.
Objectives
At this stage of the evaluation, the main research question was to assess the range and
type of initiative undertaken by FIG members. More specifically, this question was
linked to the following (summarised) general evaluation questions:




What was the mix and level of initiatives?
Were the initiatives designed to bring about changes in food and nutrition
environments?
Were the initiatives designed to bring about changes in fruit and vegetable
consumption?
Were the initiatives designed to bring about changes in consumption of high fat, salt,
sugar foods?
Methodology
166
The FIG database was reviewed to examine the overall mix and level of initiatives
members had commenced; these were classified into four areas:




Development or adoption of policies that could influence food supply or how this
was promoted;
Changes to food formulations;
Adoption of education measures such as new labelling practices or distribution of
in-store materials, and
Development of community relationships, particularly through schools or
sponsorship.
The following section examines the research questions under these headings.
Results
Policy Adoption and Development
The FIG database included three fields that examined whether members had a nutrition,
marketing or advertising policy. A total of twenty four companies were considered in
this analysis (three industry groups and the National Heart Foundation (NHF) were not
included). Table 31 reports the number of companies that entered information in these
fields.
Table 26: Identification of Nutrition, Marketing or Advertising Policies
Policy Type
Advertising
Nutrition
Marketing
1
N1
12
10
9
Companies could nominate more than one type of policy.
Although half the companies that had submitted information to the database indicated
they had an advertising or marketing policy, the form this policy took varied. Thus
while some companies noted they had specific policies in place, others provided
information about advertising or on-pack labelling they were undertaking to promote
new products they had developed (e.g. Fonterra and Tegel). Other companies provided
information about general principles, such as ensuring advertising was consistent with
broader corporate values, such as respect for families and parents (e.g., General Mills)
or principles of balance and moderation (e.g., General Mills and Progressive
Enterprises). This suggests interpretation of “advertising policy” may have varied
among FIG members. Further analysis of actual documents, and comparison of these
with current practice, will enable a clearer perspective on policy and procedure to
emerge.
167
Where information on specific policies was provided, the key provisions related to
children, specifically measures taken to reduce advertising to children. Thus some
companies noted that they did not advertise or market to children under 12 (e.g., CocaCola, General Mills, Kelloggs and Mars, and Foodstuffs stated that nearly all of their
supermarkets had at least one confectionery free aisle). However, the measures taken
were not always outlined in detail and, as indicated above, the next stage of the
evaluation will include a review of actual policy documents. For example, Coca-Cola
noted that the company “did not actively market to children under 12 years of age” and
that it “does not place television advertisements in prime children zones nor target
publications of websites designed for children”. Similarly, McDonald’s noted that they
had substantially reduced advertising expenditure on Happy Meals during “children’s
programming hours”. Yet, while “active” marketing may not occur and even though
expenditure during particular time slots may be reduced, advertising shown during
prime time spots is still likely to reach children under 12 years of age. As many children
are more likely to watch prime time programmes than those featured in designated
“children’s viewing times”, the net effect of changes in “active” marketing or reductions
in placements in particular time zones requires further scrutiny before its effects on
exposure can be estimated.
Some manufacturers linked their advertising policy with specific nutrition practices.
Thus General Mills stated only products that met their company “Guidelines for Healthy
Dietary Choices” and sugar guideline would be advertised directly to children under 12
and Nestle reported a very similar policy. McDonald’s noted that their advertising
expenditure had changed in favour of products linked to their “healthy choices and
active lifestyles” range. Similarly, Kelloggs’ database entry noted the development of
“Global Nutrient Criteria”, which the company would use to determine “which products
will be marketed to children on TV, print, radio and internet as well as how those products
are marketed, including use of license properties, web-site activities directed to children,
promotions/premiums, product placement and in-school marketing.” The use of internal
nutrition guidelines to assess which products should be promoted to children is a
potentially useful initiative that could complement the Television Broadcasters’ “Getting
it Right for Children” initiative. However, the extent to which this initiative
complements HEHA goals will depend on the nutrition guidelines, what these specify,
their link to Ministry classifications; it will also depend on how rigorously the guidelines
are applied. Nevertheless, extension of these guidelines to media beyond television
recognises the strong influence these may have on behaviour and, with appropriate
leadership, could encourage other companies to review their wider marketing practices.
There was considerable overlap between companies’ advertising and marketing
policies, which were largely synonymous. However, while companies’ nutrition policies
often informed their marketing and advertising practices, these were also linked to
wider political and social developments. For example, Coca-Cola noted that the
company’s nutrition policy was under review and, once finalised, would comprise
guidelines that would guide new product development. In addition, Coca-Cola included
in comments on its nutrition policy its agreement to remove “all sugar sweetened
sparkling drinks” from secondary schools by the end of 2009.
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Heinz Wattie’s nutrition policy noted the existence and use of internal guidelines that
were in place to “increase use of fruit and vegetables, whole-grains and beans” and that
ensured “full servings” were included in packs. Other companies noted commitments to
reduce use of trans-fatty acids and additives (Nestle and Old Fashioned Foods) and
identified policies that are discussed in more detail in the following section.
Overall, although several companies noted they had policies that included their
nutrition goals or marketing and advertising practices, the level of detail provided
varied considerably and further work is required to estimate the likely effect these
policies may have. In particular, the comprehensiveness of self-imposed marketing
restrictions requires further analysis, as does the relationship between children’s actual
viewing behaviour and times designated as “children’s viewing” zones. The next stage
of this analysis will review actual policy documents (where these can be obtained) and
compare the nutrition, marketing and advertising policies with corporate practices; this
work will use as a guide the research undertaken for the Cancer Council Australia by
Jones et al (2007).(62)
Moves to link products’ nutrition profiles with marketing programmes appear to have
more potential to change consumption environments as they propose explicit links
between demand and supply initiatives. Further work is required to assess how
widespread these policies are, the extent to which they complement media initiatives,
such as “Getting it Right for Children”, and their congruity with wider corporate
initiatives.
Changes to Food Formulations
The FIG mission statement explicitly focuses on product development and the database
captured information about product reformulations and new product initiatives that
FIG members had undertaken. Twenty six companies or industry groups reported in
the FIG database were included in this review (the National Heart Foundation (NHF)
was excluded as information provided in its entry duplicated information contained in
individual company submissions). Table 32 summarises these findings.
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Table 27: Changes to Food Formulation
Changes
New product development
Reformulation occurred
Fat reduction
Sodium reduction
Trans fat reduction
Sugar reduction
Removal of “artificial” additives
Increase in fibre content
1.
N1
21
20
17
14
12
11
6
5
Companies could nominate more than one action.
The majority of companies that had submitted data indicated they had either
reformulated existing products by reducing the fat, sodium and sugar content of these
or had developed new products that contained less fat, salt and sugar than existing
products. In addition, a smaller number had removed artificial additives (or replaced
these with ingredients they regarded as more “natural”), or added fibre to existing
products. As Table 32 suggests, several companies had extensive product ranges and so
had reformulated several different products. However, because companies’ product
ranges varied, some reformulation options were not relevant (for example, reducing the
fat content of products was not relevant to manufacturers of carbonated sugarsweetened drinks). Thus the data in Table 32 above largely reflects the product range
of the companies that submitted data (rather than general patterns in food
reformulation).
Companies removing fat from their product range had done so either as individual
initiatives or as part of collective programmes (such as “The Pie Group” and “The Chips
Group”), which were developed to promote change in cooking practices or product
composition. Several companies reported reducing the fat content of their brands; this
action resulted in changes within the biscuits, dairy products, and cereals product
categories. In other cases, companies had changed the type of fat used or the method of
cooking food. Reductions in trans-fat levels occurred through replacement of the oils
used; some companies also noted that new product development would focus on
reducing the trans-fat content of foods. In addition, the National Heart Foundation
information noted that a key focus of its “Pick the Tick” programme had been the
reduction of trans-fat levels in margarine, and fat content in dairy products.
Sodium reduction was also an important goal of the National Heart Foundation and its
database entry detailed an agreement entered into with Goodman Fielder and George
Weston foods (the two major bread manufacturers) to reduce the amount of salt in
bread. The overall objective of this alliance is to reduce sodium levels to no more than
450mg Na per 100g of bread and the initiative included reformulation of existing
products and development of new products that meet the target levels.
In addition to this major programme, individual manufacturers had also made changes
to the sodium content of the foods they produced. Some database entries referred to
company nutrition policies and the reformulation of foods to align with these, while
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others noted changes to specific product categories, including muesli and cereals, and
convenience foods.
Reduction of sugar content had also occurred in several product categories and, in some
cases, had involved alliances between manufacturers and health providers. For
example, the “Let’s Beat Diabetes” project included an initiative to replace sugary
carbonated soft drinks with “diet” drinks that had no sugar content (this initiative
involved an alliance between McDonalds and Coca Cola as well as Counties Manukau
DHB). An initial trial of this product with the “Sprite” brand had subsequently been
launched as a national initiative and work is reported as underway to replace the full
sugar Coke variant with the Coke Zero variant.
In addition, the manufacturers of sugary carbonated soft drinks reported an
undertaking that would see the removal of “sugar sweetened sparkling drinks” from all
secondary schools by 2009 (the Coca Cola database entry noted that the company had
withdrawn sugar-sweetened sparkling drinks from primary schools in 2004). Although
this initiative potentially represents a major change to food supply within schools,
further investigation of two related areas is required. First, removal of sugarsweetened sparkling drinks from vending machines will only represent a change to food
supply if it is complemented by similar changes to food available from school canteens.
The recent removal of the National Administration Guideline requiring schools to
provide only “healthy options” via canteens and tuck shops means sugar-sweetened
sparkling drinks may be available elsewhere within schools. As a result, the effects of
changes to vending machine contents needs to be reviewed against wider food supply
arrangements in schools. Second, given the specific wording of this comment, it appears
that sugar sweetened non-sparkling drinks, such as energy drinks, flavoured water and
sports drinks will still be available from vending machines placed in secondary schools.
Further monitoring is therefore also required to assess whether the reduction in sugar
consumed via sparkling sugar-sweetened drinks is offset by an increase in consumption
of non-sparkling sugar-sweetened drinks.
As well as these direct supply initiatives, several companies also reported reformulating
products to lower the sugar content, either by directly removing sugar or by replacing it
with another sweetening agent. The Confectionary Manufacturers’ Association
reported developing sugar-free products and noted an application that would enable
members to use isomaltulose as a sugar replacement. Other companies noted reducing
the quantity of sugar included in particular products; these included dairy products,
jams, cereals, muesli bars, convenience foods, and bread.
A parallel initiative involved development of products made from natural ingredients,
and that did not include added sugar, had lower sugar levels and fewer additives, or
followed “specific principles” that resulted in more “natural” products. In addition,
companies reported increasing the options available to consumers. Arguably the
highest profile of these actions has been McDonald’s introduction of “Happy Meal”
alternatives, such as water as a replacement for carbonated, sugar-sweetened, drinks
and fruit as an alternative to deep fried chips (Restaurant Brands and TPF Restaurants
reported undertaking similar initiatives). These “quick service restaurants” have also
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extended their product array, with a particular emphasis on lower fat options.
Increasing consumers’ choice directly alters food supply and is potentially beneficial if it
results in changes to food consumption. An initiative reported by McDonald’s, which
made “combos” that included a bottled water option 20 cents cheaper than the
carbonated soft drink alternative, also have the potential to affect consumer demand.
However, without longitudinal sales data, it is not possible to assess how these changes
are affecting purchase and consumption, and thus what impact on nutrition and obesity
they may have.
The removal of “artificial” ingredients is a complementary activity undertaken as
companies have reviewed product formulations or as they develop new product and
brand variants; for example, some companies reported removing monosodium
glutamate (MSG) and additives, and increasing use of natural ingredients. Others
altered product recipes to include ingredients that reportedly offer additional health
benefits, such as vitamin and mineral enrichment. Some companies also noted their
growing recognition of food allergies and had commenced producing foods that were
gluten-free, wheat-free and dairy-free or that removed “particular allergens”. However,
more specific scientific evidence is required to assess whether these initiatives have a
material effect on the quality of consumers’ food supply or obesity levels. Thus, while
new product development offers the opportunity to create “functional foods”, the extent
to which these contribute to HEHA goals requires further research, including analysis of
sales data to assess uptake of new product options and actual changes to food supply
and consumption.
As well as adding “nutrients” some companies also reported adding fibre to their
products. In some cases, these changes were made so the company could make a
stronger product benefit claim; for example, a product claim could be changed from “a
source of fibre” to “a good source of fibre”. Similarly, some companies noted that
product reformulations enabled them to make “low GI” claims. While these changes
have the potential to improve food supply, analysis of actual sales data is required to
assess the size and likely effects of food supply changes.
Overall, companies reported making several changes to their current and planned
product range; these changes included the removal of ingredients such as fat, sugar and
sodium, replacement of ingredients with “healthier” alternatives, and a general move to
develop products with higher fibre and nutrient content. Product reformulation and
development represent direct means of altering food supply; however, to have an effect
on obesity levels by improving nutrition, these changes need to be reflected in
consumer demand. Without evidence from longitudinal sales data, it is not possible to
assess consumers’ response to these changes or to identify successful initiatives that
could inform companies’ future actions.
Ultimately, evaluating the HEHA strategy and the food industry’s response to this will
require quantified information on changes in food purchases. To gain the most helpful
insights into how the FIG’s response to the HEHA strategy, estimates of sales data
should be compared to specific targets. For example, progress would be more easily
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assessed if the FIG had targets against which its actions, and the effects of these, could
be reviewed.
Adoption of Education Measures
This general category comprises two types of initiative: altering the information made
available to consumers at the point of purchase (typically via labelling changes) and
development of education programmes that might include providing educational
materials or promoting specific learning initiatives. Table 33 outlines the measures
companies reported making.
Table 28: Education Measures Implemented
Measures implemented
Changes to labels
Use of NHF “Tick”
Use of Percentage Daily Intake
(PDI) label
Use of other logo or message
Education initiatives
N
11
13
5
2
Companies reported having changed the information available to consumers by
augmenting front-of-pack labels (typically by adopting percentage daily intake
labelling). For example, Coca Cola reported featuring the “PDI thumbnail” on the front
of pack “to allow the consumer to see at a glance the amount of energy in terms of an
adult’s daily intake”. Similarly, McDonald’s reported printing PDI information on
packaging and nutrition information on the back of tray mats and Restaurant Brands
noted that burger wrappers encouraged consumers to “Have it Your Way” and
promoted greater choice in, for example, the use of mayonnaise on burgers. No
companies reported voluntary adoption of “traffic light labelling”, the approach
recommended internationally and that recent New Zealand research suggests is more
easily understood and acted upon by consumers.(63) Further work is required to
examine consumer awareness, use and understanding of the additional information
now available as initial findings suggest the utility of PDI information may be low.(64)
Other companies reported attempting to “educate” consumers by using a visual
heuristic that signified the product met specific nutrition criteria (such as use of the
National Heart Foundation “tick”). The NHF database entry noted that 60 companies
were involved in the Tick programme, that it covered 58 food categories, and was borne
by 950 different food products. Several FIG members noted products that had achieved
the NHF “Tick” standards. The Tick programme sets specific qualifying criteria that
companies must meet before their products are eligible to use the Tick; these criteria
relate to salt, fat and sugar and aim to change consumers’ food supply directly.
Furthermore, the NHF entry notes its desire to address “health inequalities in the food
supply”, a goal that is congruent with the HEHA strategy’s recognition of specific
priority groups.
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A small number of companies had developed messages that fostered healthy eating
practices. For example, the Confectionery Manufacturers’ Association entry referred to
a “Be Treatwise” message that was used to complement the serving size information
provided in standard Nutrition Information panels and that appeared to promote
moderation. Heinz Watties noted the launch of a “Healthy Pick” logo that was used in
“Food in a Minute” recipes, where these met overall company guidelines for food
nutrition (full details of these guidelines were not available in the database entry).
Comments in other entries suggest companies were also motivated to change the
composition of their products so these achieved more favourable classifications. For
example, “The Pie Group” noted that some reformulated products could be sold “in the
‘sometimes’” category under the new Food and Beverage Classification System”. Other
labelling changes also related to information that could be used to communicate specific
attributes; for example, La Bonne Cuisine reported changing nutrition labels so that
“low fat products and gluten free products” were clearly labelled. Similarly, Progressive
Enterprises noted that details of fibre content were now being included in the Nutrition
Information Profiles (NIPs) of “applicable products” and that a “Free from” range had
been developed to meet the needs of people with allergies.
Other initiatives that may have altered consumers’ food supply involved changes to food
package sizes. Eight companies reported changing pack sizes or introducing new pack
size options. Coca Cola reported introducing 300ml “slimline” cans and 385ml glass
bottles; these are sold predominantly through service stations thus the effect of this
initiative to influence consumption is limited by the distribution arrangements
currently in place. The Confectionery Manufacturers’ Association reported that smaller
portion sizes had been developed to “fit a wide range of consumer age groups and
profiles”, and Fonterra noted that it had developed smaller “squeezable” packs (125ml
cf. standard product size of 150ml). In addition, it had reduced the serving size of
speciality and core cheeses (to 20g and 25g respectively). Other manufacturers noted
they had developed smaller standard serving sizes or sold products as single serve
items to support portion control. Heinz Watties was the only company to report
deleting a large size variant (its report noted that the large size of “Big Eat Hash
Browns” had been deleted. As with other initiatives, the effects of these measures can
only be assessed by examining longitudinal sales data.
Other educational practices included providing education materials; some of these were
provided in store (such as recipe leaflets and nutrition brochures) while others were
programmes delivered through schools or other groups. Many companies reported
making educational material available via their websites and some had extended these
efforts into brochures that were widely distributed, such as Coca Cola’s “Make Every
Drop Matter” initiative. Retail chains such as Foodstuffs and Progressive Enterprises
had developed specific campaigns, such as “Live Smart” a programme that included
point of sale material such as recipes, and website information. One company
(Restaurant Brands) also reported requiring staff to complete a training module that
included information about product nutrition.
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School initiatives reported varied widely and included elements of corporate policy and
wider agreements, such as the programme to remove sugar-sweetened sparkling drinks
from schools. Initiatives that were integrated with classroom activities included “Food
for Thought” a Foodstuffs programme covering nutrition topics and involving store
visits and a subsidised “healthy lunch”, that was designed for Year 5-6 students
(Progressive Enterprises ran a similar initiative: “Fresh Food Kids” and supported the
“Red Cross Breakfast in Schools” programme). Heinz Watties also had several
education-based initiatives that included “Project Cook”, aimed at intermediate school
students, “Healthy Mums”, “Fruit and Vege Each Day” brochures and “Food in a Minute”
recipe leaflets. Nestle made teaching resources available to intermediate schools (“Be
Healthy, Be Active”) and products cookbooks, booklets and posters in addition to
making information available via its website. Sanitarium also reported on its “NuForce
5” programme which appears to be directed at assisting teachers to help children make
healthy food choices.
Overall, companies had embarked on several initiatives that changed or increased the
information provided to consumers. However, while open access to information is, in
principle, a good thing, its effects will depend on how well consumers can understand
and use that information. At present, the evidence suggests that information provided
in PDI (and NIP) labels is not easily understood, thus while this may be designed to
inform consumers’ choices and assist them to choose options that are lower in fat, salt
or sugar, the extent to which food labels influence behaviour is not clear.
Initiatives that provide information at the point of sale may be more likely to influence
consumption, although this possibility also needs to be evaluated using actual sales
data. School based education initiatives may promote nutrition knowledge but closer
examination of the materials provided, the duration of the programme, its integration
with other curriculum elements, and its consistency with other school practices (such as
food supply via canteens) is required. Initial assessments of website information could
be made by monitoring site visits and downloads, although this would provide
information on what consumers accessed (rather than what they used and how they
used it).
Community Relationships
The HEHA strategy aims to develop links between groups and several of the FIG
database entries outlined initiatives that built or extended community relationships.
Some of these have already been outlined in the section above (those that involved
providing educational materials or that developed relationships with schools).
However, companies outlined several other activities that they had initiated. Perhaps
the most extensive of these is the “Let’s Beat Diabetes” alliance discussed above, which
involved Coca Cola, McDonald’s and Counties Manukau DHB working together on
changing the type of drink provided by Coca Cola in McDonald’s stores. Other alliances
with external groups included the Foodstuffs relationship with the NZ Cancer Society;
the “Livesmart” programme aims to promote consumption of fruit and vegetables and
uses point-of-sale educational materials (such as recipe leaflets). In addition,
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consumers who register with the website can receive newsletters that provide nutrition
and exercise tips. This project was also part of the “Let’s Beat Diabetes” programme, as
were initiatives undertaken by retailer Progressive Enterprises.
Progressive
Enterprises’s contribution also involved provision of POS materials relating to both food
and nutrition, and the “Swap2Win” programme, which encouraged families to change
from blue (full fat) milk to light blue (reduced fat) milk.
Several companies were involved in sponsorships that were related to nutrition; for
example, Watties sponsorship the “Volunteer Coach of the Year” awards, while
Hubbards sponsored “Read Duathalon” and “Carbon Crusade” as well as providing
scholarships to food technology students. Nestle reported involvement in several
sports sponsorships, particularly those involving children, and noted community links
with Kidz First, Cure Kids and Lifeline, while Sanitarium supported the nationwide
“Weet-Bix Tryathlon” programme.
Overall, while developing community relationships and supporting local programmes
can provide many benefits to the sponsored groups, concerns have been raised about
the access these programmes provide to children. The sponsorship entries in the
database appear to be incomplete (for example, QSR companies did not list
sponsorships in which they are involved) and further research could explore how
community and corporate benefits are balanced.
Limitations
The main limitation affecting data entered in the FIG database is that it is self-reported
and not comprehensive. Thus while there is information about several companies’
efforts to reformulate products, develop new products, assist consumers and develop
relationships with the wider community, it is not clear how these efforts fit within their
overall activities. For example, developing smaller portion sizes and products with
lower fat and salt content may have little overall effect if a company’s marketing efforts
continue to support products that are served in large portions and have a high fat and
salt content. A full assessment of FIG members’ initiatives and the effect these have had
on New Zealand’s food supply requires access to longitudinal sales data so that changes
in purchase can be identified and trends determined.
Conclusions
Information from the FIG database suggests the initiatives comprised policy change,
food reformulation or new product development, consumer education, and
development of community relations. This mix of initiatives reflects internal changes
(such as policy development) as well as changes that more directly influence
consumers’ food supply (such as the marketing of new foods). In particular, food
reformulations and development of foods with healthier profiles has the potential to
improve nutrition and contribute to reductions in obesity. The vast majority of the
initiatives reported were designed to reduce consumption of high fat, salt and sugar
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products, typically by changing the composition of these. Only a small number of
initiatives aimed to increase fruit or vegetable consumption; those that did either
promoted alternatives (i.e., replacement items such as fruit rather than chips) or
emphasised the use of fresh ingredients in product reformulations.
Each of these initiatives could change consumers’ food supply and consumption
behaviours. However, it is not possible to estimate this potential or its likely effects
from the information provided. As noted, the information is an incomplete
representation of companies’ wider product profiles and activities; the effect of
initiatives outlined in the FIG database can only be considered by examining consumers’
wider food environments. If the FIG initiatives represent a substantial change to that
environment and are supported by other company practices, their potential effect on
likely consumption will be great. Conversely, if these initiatives are not part of
companies’ mainstream practices, their likely effect will be correspondingly smaller.
The FIG database did not include an “evaluation” field, thus it is not clear whether the
actions reported have been formally reviewed. Such reviews are imperative if the
effects on consumers’ purchase behaviour are to be documented; knowledge of these
effects is vital to estimating changes in fruit and vegetable consumption, and
consumption of high fat, salt and sugar foods. As noted earlier, this assessment would
be especially useful if it evaluated FIG members’ actions against defined targets, since
this would enable the effect of food supply changes on food purchase to be quantified.
Case studies that examine detailed changes in specific companies’ food and beverage
offerings and consumers’ response to these are required to examine whether initiatives
designed to bring about change in consumption of high fat, salt and sugar products
actually did so. Development of these case studies would require access to companies’
sales data, which may be difficult to obtain, although the value of independent
evaluations of these data should promote their release. Without these data, it will not
be possible to estimate the effect of FIG members’ initiatives or to test claims about the
impact these have had.
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Section 5: Value for Money
Summary
 One of the key questions for the evaluation is: has the HEHA Strategy and its
implementation resulted in value-for-money?
 This first report focuses on identifying the national level funding provided for
HEHA, the range of initiatives allocated money at DHB level, early views of key
informants on whether the Strategy and its implementation are likely to result in
value-for-money, and an indication of the best mix of initiatives to maximise
outcomes.
 A consideration of exactly what HEHA is and which initiatives it comprises is
required. This is not always agreed amongst key informants. Consequently, we
identify alternative ways of thinking about HEHA.
 From an analysis of budget documents and stocktake data, we have identified
high-level funding for HEHA-related activities at around $328 million between
2005 and 2010, although this is likely to be an under-estimate given the large
number of initiatives where no budget information was available.
 Initiatives stocktake data was recorded at the individual programme level.
Funding data for 437 of the 1256 recorded programmes shows that funding was
predominantly allocated to nutrition and physical activity programmes in
community and educational settings, with a child and family/whānau population
group focus.
 Budget documents data shows proposed funding allocations by area of activity
(e.g. leadership, breastfeeding, primary care), which differ from the outcome areas
identified for stocktake initiative. This makes detailed comparisons between the
two funding data sources extremely difficult, however school and community
focussed workstreams were also consistently amongst the highest funded
workstreams in the annual budget allocations. No actual expenditure data were
available.
 Key informants were also asked about their current views on whether HEHA
would offer value-for-money, and about a number of funding-related issues.
 The responses were generally positive although there was an understanding that
this was very much based on the potential of HEHA, as it is recognised that it
would be some time before clear measurable impacts will be seen. But across a
number of agencies it was felt that the Strategy would offer value-for-money. It
178
was acknowledged, however, that there was a risk the HEHA may not bring about
the desired level of benefit, although the risk of doing nothing was seen to be far
greater.
 Funding for HEHA was generally seen to be adequate or at least matched to
existing capacity, although NGOs would like more funding and some suggestions
were made for further investment. Some respondents commented on the amount
of time needed for the establishment phase and to build capacity, while some
DHBs noted that they contributed their own additional funding to HEHA-type
work while others reported having no access to other funding beyond that
allocated by the MoH.
 Many key informants felt that there was little or “no security whatsoever” in
relation to HEHA funding at present, and were concerned over the potential
damage that withdrawing funding from community projects could have on
working relationships.
 Key informants noted the initial difficulty in identifying what works in relation to
HEHA, given the lack of evidence on this, and the need to rationalise funding
allocations as the evidence-base improves.
 In general, HEHA is seen as prescriptive, and some DHBs were concerned over
resource allocation particularly with the number of project manager and district
co-ordinator positions, as there was one of each position for each DHB, regardless
of its population size. DHB key informants also desired more local flexibility in
determining their own spending priorities and more consultation with the MoH
over funding decisions and priorities.
 Limited information could be gathered on the mix of initiatives likely to maximise
achievement of HEHA Strategy goals, due to several methodological limitations.
However, some indications of the programmes most valued by key informants
were gained. Valued programmes included: the Nutrition Fund and education
District Coordinators; the enhanced Green Prescription programme; the
Community Action Fund to address health needs within Māori and Pacific
communities; breastfeeding initiatives; and leadership and coordination of HEHA
programmes at DHB level.
 Resources may be able to be redirected towards the highly valued programmes
through: small marginal cuts across the range of programmes, particularly
communications; improving targeting of programmes to community health needs;
and reducing duplication between programmes.
Introduction
An important aspect of this evaluation is to assess whether or not the HEHA Strategy
and its implementation have provided value-for-money. This aspect of the evaluation
179
will focus on three key issues. First, we aim to assess the effectiveness of the HEHA
initiatives in achieving immediate, intermediate, and long term outcomes, and thereby
identify the benefits (outputs and outcomes) from the HEHA Strategy, and to compare
these with the costs associated with the implementation of the HEHA Strategy, that is,
with the resources used in implementation. Second, the evaluation also aims to identify
whether or not greater benefits might have been obtained from alternative uses of the
resources used in implementing HEHA. Third, the evaluation will consider the
institutional context within which HEHA has been implemented, and the incentives
which operate for different agencies involved in the implementation of HEHA, in order
to assess whether the institutional arrangements are supporting or detracting from the
implementation of HEHA.
This interim report includes data and analysis on the first two aspects of the value for
money analysis, identifying the high-level funding allocated to HEHA (from
documentary analysis and stocktake data), and providing some information from key
informants on their perceived value of HEHA initiatives (from a first round of key
informant interviews), and possible alternative uses of resource (from a second round
of key informant interviews). Greater detail on the methods used and limitation of the
analysis is discussed below. Further detail on the full proposal for assessing value-formoney is set out in Appendix 5.
Research Questions
The key evaluation question here is: Has the HEHA Strategy and its implementation
resulted in value-for-money?
Methods
As noted above, the first focus of this report was to identify the high-level funding
allocated to HEHA. This included identifying and analysing the mix of initiatives funded
by and linked with HEHA.
Two data sources are used for this aspect of the evaluation:

‘Budget’ allocations identified from analysis of key documents, including Cabinet
papers, Ministry of Health business plans and MAPs.

‘Stocktake’ allocations identified from the stocktake of initiatives see Section 3:
Stocktake of HEHA Initiatives
All amounts reported here are agreed budget allocations of funding rather than actual
expenditure. Budget data has been pooled within HEHA workstreams or intervention
groups, and as a result there was very little funding detail available to us regarding
individual programmes. Stocktake data were recorded for individual programmes and
are predominantly based on the MAPs, in addition to the ANA database and some
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evaluations, and were therefore self-reported. This raises a number of issues with the
stocktake data.
First, the data are not necessarily complete: for example funding data was only available
for 437 of the 1256 identified programmes despite attempts to gain details from
alternative sources. However, comparing some of the descriptive data, such as
programme type, setting, target populations and outcome targets, shows that overall,
the 437 ‘funded’ sample was quite representative of the 1256 total. Some minor
differences between ‘funded’ sample and the full set of initiatives include: the ‘funded’
sample tend to identify initiatives as relevant to a greater number of settings,
population group and target outcomes; more ‘funded’ initiatives were identified as
targeted to child, family/whānau, low socio-economic, Māori and Pacific population
groups; and more ‘funded’ initiatives were identified as targeting obesity outcomes
compared to the full initiatives set. Comparative figures can be found in Appendix 5.
Second, data may not always show the detail of funding sources where funding is
provided by several funders to a central pool and then allocated from the central pool
by a single funder: for example, the funding source for all the Mission-On programmes
was reported in the stocktake as being solely SPARC, whereas there were actually three
funders of Mission-On – in addition to SPARC, the Ministry of Health’s HEHA budget
covers some Mission-On initiatives and there was also a contribution from the Ministry
of Education. Thirdly, there is overlap within the stocktake data sets, as the stocktake
was aimed at capturing as much detail as possible regarding individual programmes
and most programmes have more than one target population, expected outcome, or
setting. As a result funding was not broken down specifically to represent different
elements within each programme. For example ‘Feeding our Futures’ is listed in the
stocktake as a breastfeeding initiative, and while there is an element of breastfeeding
within the programme, it is fundamentally a social marketing campaign. And finally, the
MAPs reported some programmes as starting some years prior to the introduction of
HEHA, in some cases as early as 1994. This makes any detailed comparison between
budget and stocktake funding data very difficult, as the budget data are available only
since the 2005/06 financial year.
Another issue that has contributed to making any financial audit or reconciliation
exercise more difficult is that it has also come to light, through key informant
interviews, that some of the programmes recorded in the MAPs may not have run as
they were planned, with some not actually starting, while others have changed name
since the MAPs were drawn up.
The second value-for-money focus of this report is on the perceived value of HEHA
initiatives from key informants, including identifying alternative uses of resources to
achieve the intended outcomes of the HEHA Strategy. This was not designed to
determine value-for-money of the HEHA Strategy as a whole, which requires longer
time frames and population level data on physical activity, nutrition and obesity
outcomes. It does give us an idea at this point of time about where key informants
believe HEHA is working and how to better allocate resources to improve value-formoney.
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Two rounds of key informant interviews have been conducted on value-for-money
issues. The first round, described in Section 1, took place between January and April
2009. As part of wide ranging interviews that asked key informants about funding
sources, the initiatives funded and sufficiency of resources, questions were also asked
whether HEHA was seen to be producing value-for-money. The interview transcripts
were analysed thematically, focusing on the responses to the key value-for-money
questions in the interview schedule, but also on related responses to other questions.
The second round of key informant interviews took place between September and
November 2009. A sub-set of key informants involved in the first round of interviews
were again contacted. These key informants were limited to Central Government, DHB
and PHU informants who would have an overview of HEHA funding and initiative
outputs. To consider whether greater benefits may have been obtained from alternative
use of resources, a programme budgeting marginal analysis (PBMA) approach was
chosen. PBMA seeks to compile a programme budget and then work with informants to
conduct a marginal analysis to assess the impacts of changing costs or benefits. PBMA is
a tool for considering the mix of activities to achieve maximum benefit from a given set
of resources. PBMA is based on the economic principles of opportunity cost of not
undertaking alternative activities, and marginal analysis of the benefit gained or lost
from having one additional or less unit of activity (65, 66).
Twenty interviews were conducted by phone and face-to-face, using a semi-structured
interview format designed using the PBMA method. The interview schedules are
included in appendix 5. Originally around 35 interviews were to be conducted in this
second round, however the data were proving to be of limited use, for reasons
described below, and a decision was made to end data collection early.
The interview guide included questions on: the number and budget of HEHA initiatives
in the organisation or geographic area relevant to the key informant; recent changes to
HEHA funding and/or initiatives; if funding had been cut, where this money had been
directed; how decisions about funding allocation were made; how any cuts impacted on
initiatives; implications for achieving HEHA Strategy goals; and what programmes
would be kept or cut if further reductions in budgets were required. The interviews
were recorded and detailed interview notes were made. Upon request, interview notes
were returned to informants to check accuracy (about half of the informants requested
to see notes), with minor changes made to a few interview notes.
A thematic analysis was conducted of interview notes under broad categories of
interview questions – changes to budgets and programmes, impact of changes and
perceived value of programmes. We separately noted issues raised about allocative
efficiency (were the right things being done) and technical efficiency (were things being
done right).
The PBMA method was originally going to include informants from all DHBs, Public
Health Units and several Central Government agencies. However, it became apparent
after about 15 interviews that the information being collected was of limited use for the
182
method, and it was decided to stop interviews. Four somewhat related issues limited
the ability to conduct a PBMA analysis: difficulty in determining the value of initiatives
due to the early stage of implementation and the small size many initiatives which limits
the intended outcomes; limited evidence of effectiveness or efficiency of initiatives; the
apparent close tie between institutional arrangements and value for money
considerations; and the changing context of the HEHA Strategy, with re-prioritisation of
funding for several programmes to other health services and further funding decisions
imminent. These themes are explained further below. These four types of limitations
have been noted in the PBMA literature as potential problems with the method (67).
Determining value – HEHA related programmes and initiatives within a DHB
geographical area were funded through a mixture of DHB-controlled and direct MoH
contracts. DHB-based key informant knowledge of direct MoH contracts was variable.
Within DHB control, there were many small projects funded through Nutrition and
Community Action Funds. Informants had difficulty identifying marginal gains or losses
within a fund, although a few suggestions were made and are described below. Several
informants suggested that the value of activity within the funds came from a mixture of
the engagement of communities in nutrition and physical activity, as well as the specific
projects themselves. For this reason, the value of particular projects, such as
community gardens, seemed difficult to compare to other projects within a funding
pool, such as cooking classes, because the specific initiative benefit could not be
distinguished between the community engagement benefits gained through the process
of funding initiatives. It was also not possible to separate out the value of initiatives
occurring prior to HEHA with those funded through HEHA budgets. For example
several informants described Nutrition Fund projects building upon existing school
stakeholder networks developed through health promoting schools work within PHUs.
Availability of evidence on which to base value judgements – Many of the projects funded
through the Nutrition and Community Action Funds have been small, and many are
ongoing. Not all have been evaluated for their impact on nutrition and/or physical
activity outcomes, as the timeframe within which to do this has been too short and/or
the sample size too small to assess outcomes in many cases. A lack of evidence of
project effectiveness also hampered the degree to which informants could consider the
value of specific projects. All informants did have knowledge of population health
strategic priorities relevant to their area, however this type of information was more
relevant for macro ‘between programme’ analysis (e.g. nutrition related projects
compared to sports), rather than micro ‘within programme’ analysis (e.g. school water
fountains compared to working with the food industry).
Close tie between institutional arrangements and marginal value – Where informants did
identify areas for gains or losses through changes to programmes, these often related to
institutional arrangements between the Ministry of Health, DHBs and communities. The
interview guide was not designed to collect detailed information on institutional
arrangements, as this is the focus of the third part of the value-for-money analysis, to be
conducted later in the evaluation. While the information being collected is interesting,
more robust findings will be collected with methods designed specifically for this
purpose, and reported in mid-2010.
183
Political context of HEHA Strategy and funding – Related somewhat to the institutional
arrangements, over the course of 2009 some of the funding for HEHA was reprioritised to other health services. Every key informant was impacted to some degree
by the reduction in HEHA funding and reported making funding changes directly related
to reduced funding streams rather than by their own choices about the relative value of
different activities.
Several informants seemed to have difficulty thinking about
marginal changes in funding and programmes in the context of reduced funding.
Results
Value-for-Money in Budget Proposals
A Vote: Health Budget Proposal for funding the HEHA Implementation Plan 2004-2010
(68) argued that diet and physical activity combined make the highest contribution to
premature death in New Zealand (about 11,000 deaths in 1997), and obesity alone was
estimated to contribute to between three and six percent of healthcare costs. These
impacts were expected to continue to rise without intervention. A disproportionate
burden of the health impacts were noted to fall on Māori and Pacific peoples.
A rapid analysis was conducted to estimate the potential cost-effectiveness of funding
and implementing a greater range of interventions in the HEHA plan for the years 2006
to 2011, compared with the (then) status quo of limited interventions directed at cancer
prevention. The rapid analysis results suggested a cost-effectiveness ratio of $30,000 to
$100,000 per life saved, or $3,000 to $10,000 per year of life saved. Conservative
estimates relating to the benefits of HEHA in terms of life years and lives saved and
relating to the costs of obesity-related illness suggested a cost-effectiveness ratio of
closer to $10,000 per year of life saved. Using the Ministry of Transport estimates of a
$150,000 value for a life year, the Proposal for funding the HEHA implementation plan
suggested that these results would provide significant savings to society (68). It must be
noted however that even in the Transport area, NZ has not been able to fund all the
initiatives which cost up to $150,000 per life year (given budget constraints). PHARMAC
reports funding new investments at around $6,900 per Quality-adjusted life year
(QALY) gained on average, although the annual cost ranged from $2,991 in 2001/02 to
$15,768 in 2003/04 (69). Thus, if the HEHA programme were to produce costeffectiveness ratios at the high end of the estimates ($10,000 per year of life saved), the
programme could be considered marginal. The total budget amount used in the above
calculations is not specified in the documentation. The cost-effectiveness calculations, if
calculated for the actual budget allocated to HEHA programmes and initiatives, may
differ from those quoted above.
Treasury assessment of the Ministry of Health HEHA funding bid noted that “Treasury
recognises the high priority of addressing obesity and encourages initiatives aimed at
this purpose”, but considered that some of the evidence for cost and benefits from
HEHA was questionable, and queried whether some of the benefits would be achieved
within the timeframes suggested in the rapid economic analysis.
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Defining HEHA
In assessing whether HEHA has offered value-for-money or not, the research team
needed to be clear about which initiatives were actually HEHA initiatives and which
were not. This emerged as a key issue from some of the key informant interviews, and
was also evident when direct requests were made for evaluation and funding details for
individual initiatives as part of the stocktake of initiatives. This was in part a question
of ownership of the Strategy, as many reported HEHA as being seen as ‘very much a
Ministry of Health programme’.
Thus, not all informants agreed about whether they were actively engaged with HEHA,
nor whether the initiatives they were involved with should be considered to be a part of
HEHA. This was certainly the case with those agencies and stakeholders whose focus of
work had always been based around physical activity, nutrition and/or health
promotion. In some cases, this was reinforced by the attitude that HEHA is a standalone and time limited strategy, rather than viewing HEHA as an attempt to ensure its
key messages are incorporated into future ways of working and living. Some
differences in whether initiatives were classed as HEHA also emerged in the HEHA
documents, with some initiatives included as HEHA in one document at one point in
time but with a different label in a later document. Yet to answer the value-for-money
evaluation question in particular, we need some clarity around which components of
expenditure were considered to be HEHA and which were not.
There are a variety of approaches that could be taken to identifying what HEHA is and
which initiatives it comprises. One approach might identify the resources and funding
or particular initiatives which are considered to be HEHA, with the evaluation following
through particularly on these. Alternatively, an outcomes-oriented approach might
identify all the resources, funding and initiatives which are contributing to the longterm goals of improving nutrition, increasing physical activity and reducing obesity.
This latter approach is, however, beyond the scope of what can feasibly be included in
this evaluation.
The difficulty with identifying HEHA and HEHA initiatives arose from a number of
features of the HEHA Strategy itself. In particular, HEHA could be considered to be a
‘banner’ under which a wide range of initiatives fall; its focus on co-ordination within
the health sector and across sectors, of involving a wide range of stakeholders, of coordinating across already existing initiatives, or re-orienting existing expenditure
towards HEHA goals and objectives, and of aiming to mobilise resources from a wide
range of organisations, means that it became difficult to clearly delineate HEHA
initiatives from non-HEHA initiatives.
The approach we have chosen at this point is to identify the different criteria which
might be used to determine if funding or initiatives were HEHA or not, and thereby
identify the potential scope of HEHA and a range of estimates of the funding associated
with HEHA. It is this range of estimates that we will use in assessing value-for-money.
185
The key criteria we have identified which could be used to identify HEHA are:
 Timing – some initiatives predate the release of the HEHA Strategy and hence
might be considered not to be a part of HEHA, e.g. Push Play, Green Prescriptions,
Public Health Unit (PHU) funding to support nutrition and physical activity
initiatives. However, some of these initiatives may have had additional funding
allocated to them, partly as a result of the focus on HEHA, so that new funding
following on from the release of the HEHA Strategy could be considered to be a
part of the HEHA Strategy.
 ‘HEHA-funded’ – some initiatives may be described as HEHA-funded and included
by organisations in HEHA funding bids and allocations, while other initiatives are
not. For example, the MoH notes that PHU funding is excluded from its funding
pool of HEHA-funded initiatives (9, p6), even though services purchased by the
MoH through the PHUs have been realigned to support HEHA (10, p4). In
presenting their MAPs, DHBs were asked to separate initiatives by whether or not
they are HEHA-funded, but there did not appear to be an official standard
definition as to what constituted HEHA, and we assumed that interpretation of
what was HEHA-funded had been left to the discretion of individual DHBs.
 ‘Contributing to the Implementation of HEHA’ – in some documents, there was a
category of initiatives labelled as ‘Contributing to the Implementation of HEHA’,
which include Mission-On; the Tripartite Agreement (Partnerships in Action)
initiative developed between the Ministry of Health, SPARC and the Ministry of
Education; Push Play; Live Smart; and the Green Prescription initiative (9, 10). A
number of DHB initiatives were also identified as contributing to the
implementation of HEHA, such as the Let’s Beat Diabetes initiative in Counties
Manukau (which also predated the release of the HEHA Strategy); Project Energize
in the Waikato; the Waitemata Beverage Project (10, p18); the Mangere Healthy
Kai project; Ngati and Healthy (again which seems to have predated HEHA); the
One Heart Many Lives cardiovascular programme developed by PHARMAC;
Oranga Tu Tonu in Lakes DHB; Shake it, Beat it, Learn it, developed for the Pacific
community in Capital and Coast DHB; and the Tongan Community Action
Programme in Christchurch.
 ‘HEHA Project Team Related’ – similarly, in some documents there are initiatives
mentioned which are noted as not being the responsibility of the HEHA project
team. This includes the funding which is allocated through PHUs (10,p6), and also
some breastfeeding initiatives: for example, the Baby Friendly Hospital Initiative
was, in 2007, included as a HEHA initiative (10, p8) while in 2008/09 it is noted to
be one of a number of initiatives on breastfeeding which are not led by the HEHA
project team (9, p15).
 Non-HEHA funded – it will be particularly difficult throughout the evaluation to be
clear about the resources being used for HEHA and to achieve HEHA goals and
186
objectives where no particular HEHA funding source can be identified. For
example, national government agencies may spend time on HEHA-related
activities (e.g. through key stakeholder meetings) but their time may not be
funded in an identifiable way as HEHA. Similarly, key stakeholder groups at a
district level will be involved with HEHA meetings and initiatives, but their time
too may not be funded by HEHA; rather, it may be provided to HEHA as a ‘free’
resource, funded by other funding sources such as other government (e.g. PHU) or
district programmes or other sources (e.g. donations, co-payments for services,
etc). Similarly, some initiatives may be non-HEHA funded but receive specific
funding for their support (e.g. through DHBs, NGOs, PHOs, etc). The stocktake of
initiatives provides more information on the funding from other organisations, but
is not included in the allocation estimates set out below.
 Implementation Plan – a final approach is to consider all initiatives included
within the HEHA Implementation Plan (8) as HEHA. However, the Plan included a
wide range of initiatives across a very wide range of agencies and was, in some
cases, fairly general in its description of the initiatives. It also was not clear within
the Plan whether funding had been allocated to support the specific initiatives
included within the Plan, while implementation may not have exactly followed the
Plan in any case.
Our approach was to aim to track key funding allocations which might be considered,
under some definitions, to be HEHA-funded and HEHA-related, and to identify the
different initiatives according to the criteria set out above. However, when we later
come to assess value-for-money and work to link inputs to outputs to outcomes, while
the original funding category may be clear, clearly linking inputs to key outputs will be
difficult, especially where initiatives are jointly funded or where multiple sources of
funding are used to fund a particular initiative. It will be even more difficult to clearly
link inputs and outputs to the outcomes which are achieved in relation to nutrition,
physical activity and obesity, given (as is clear from the above discussion) the wide
range of funding and initiatives – not all of which are always considered to be HEHA –
that may be contributing to those outcomes.
Funding Allocations for HEHA
The HEHA Strategy was released in March 2003, and the Implementation Plan 20042010 was released in June 2004. However, significant funding for HEHA was not
obtained until the 2005/06 financial year. Prior to this, in 2004/05, existing funding for
nutrition and physical activity (around $10m) was ‘realigned to meet actions mentioned
in the HEHA Implementation Plan’ (10,p4).
Budget Allocations
In 2005/06, $7.2 million (GST exclusive) of Cancer Control Action Plan (CCAP) funding
package was allocated to implement the HEHA Implementation Plan; the funding
covered four main work areas:
187

Fruit in Schools

DHB Innovations fund

Public Awareness Campaign

Evaluation & Research (10).
In 2006/07 a further $0.7 million was added to CCAP and further funding of $19.033
million was allocated to HEHA; total HEHA-related funding at that time was sourced as
follows:
Table 29 HEHA related funding 2006/07 ($ million per annum, GST exclusive)
Public Health Baseline, Nutrition & Physical Activity
Cancer Control
HEHA budget 2006/07
TOTAL
13.211
7.900
19.033
40.144
Source: Ministry of Health: Health Report Ref. No.:20061898 (29 September 2006) and Progress of
Implementing the HEHA Strategy 2008
In 2007/08 an additional $12.45 million of funding for HEHA was approved and Public
Health Baseline, Nutrition and Physical Activity funding was increased from $13.2 to
$17.057 million per annum (this is funding which is not the responsibility of the HEHA
project team).
Table 30:HEHA-related funding 2007/08 ($ million per annum, GST exclusive)
Public Health Baseline, Nutrition & Physical Activity
Cancer Control
HEHA budget 2007/08
TOTAL
17.057
7.900
31.483
56.440
Source: Ministry of Health: Health Report Ref. No.:20061898 (29 September 2006) and Progress of
Implementing the HEHA Strategy 2008
The2007/08 HEHA work programme covered the following areas of activity:
HEHA Sector Capability and Innovation
The aim of this activity is to facilitate a partnership approach and collaboration at
district and national levels, in order to implement HEHA.
Leadership
HEHA is driven nationally by the Ministry of Health (and by SPARC for the physical
activity-related actions) through internal and external HEHA co-ordination groups.
Between 2004 and 2007 there was also a tripartite agreement between Ministry of
188
Health (MoH), Ministry of Education (MoE) and SPARC to enhance coordination and
alignment of initiatives and resources in relation to improving the health of students.
District Health Boards are funded to be regional co-ordinators and to mobilise
community action around HEHA initiatives. The co-ordinating role for each DHB has
included: establishing a project manager, a HEHA group to co-ordinate stakeholder
agencies, an education sub-group, developing a Ministry approved district plan and
communications plan, and employing a district co-ordinator to work with schools and
early childhood education centres (see below).
HEHA Community Action Project
Community action is recognised in the Ottawa Charter and is considered an important
vehicle for creating sustainable change. In New Zealand, community action to address
issues such as those relating to nutrition and physical activity for Māori and Pacific
peoples, is acknowledged as the most effective way to influence change at the
community level. The HEHA Community Action Project focuses on engaging and
mobilising Māori and Pacific communities through DHBs. Māori and Pacific
stakeholders informed the development of service specification and the Action Project
has adopted a whole of whānau/family approach to influence changes related to
nutrition and physical activity at the household and community level. In 2007 the
HEHA budget allocated funding for community obesity prevention projects to
implement and support projects in Māori and Pacific communities.
Schools and Early Childhood Education Settings
The aim of this activity is to improve the nutrition of young New Zealanders. Activity in
the school setting comprises of Fruit in Schools and the Nutrition Fund to promote
healthy food consumption, and nutrition and physical activity workforce development
within early childhood education (ECE) services and schools. Fruit in Schools provides
participating students with a free piece of fruit every day and targets low-decile schools.
The Nutrition Fund supports the implementation of the Ministry of Education Food &
Nutrition guidelines for schools and ECE centres as well as helping to increase capacity
and capability by supporting guideline implementation through professional
development opportunities for teachers. District co-ordinators support schools and
ECE services in making changes to improve the nutrition environment and co-ordinate
the Nutrition Fund grants process. Part of the Mission-On initiative (between the
Ministries of Health, Education, Youth Development and SPARC) is also related to
schools and ECE initiatives (9, p12).
Breastfeeding
Breastfeeding is one of the key HEHA messages; the aim is to increase breastfeeding
rates, particularly amongst Māori and Pacific women who have lower rates of
breastfeeding than the non-Māori and non-Pacific population, through national and
community based campaigns. Initiatives here include the development of a National
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Strategic Plan of Action for Breastfeeding, development of a national social marketing
campaign, the development of DHB breastfeeding action plans, and workforce
development. Related work, not the responsibility of the HEHA project team, also
provides support for the Baby Friendly Hospital and Baby Friendly Community
initiatives.
Communications
This involves promoting the HEHA key messages with particular focus placed on
priority audiences by engaging stakeholders and raising the profile of HEHA through
the development of a national HEHA network and a public health awareness campaign.
It includes a national social marketing programme, Feeding our Futures, a three year
campaign using television, radio and print material to improve nutrition and eating
practices for families and children, and the national breastfeeding social marketing
campaign. It also includes a HEHA network initiative to enable key stakeholders to
communicate in an interactive way, share learnings, ideas and evidence and avoid
duplication. A HEHA newsletter is also a part of the communications initiatives.
NZWell@Work is the government’s Walking the Talk initiative, part of Mission-On and
aimed at encouraging the state sector to build workplace health promotion of healthy
eating and healthy action.
Primary Health Care
The main focus of HEHA in the primary health care setting is to develop and implement
national guidelines for the management of people who are overweight and obese. This
includes a training package for use by health professional s to ensure a consistent
evidence based approach for the treatment of overweight and obesity. In addition,
there is an Innovations Fund to support community action to improve nutrition and
physical activity as well as provide a financial incentive for primary health
organisations to reorient their activities to include a public health approach.
Industry
This involves working alongside the food and advertising industry to improve the
nutrition environment, including the production, supply and marketing of food. The
food industry projects include reducing the salt, fat and sugar content of high-volume,
low-cost food. With regard to advertising, the Ministries if Education, Broadcasting and
Health have an agreement with major television broadcasters on a five-point plan to
improve food advertising for children and includes the Children’s Food Classification
System which imposes restrictions on television advertising of foods and beverages
during children’s programming times.
Research, Monitoring and Evaluation
This activity aims to ensure effective evaluation of the Strategy by understanding the
implementation process, assessing whether it is achieving its objectives and is valuefor-money; a key component is the provision of results to the Ministry, stakeholders and
190
the sector. In addition, the HEHA DHB Evaluation Fund supports regional and district
providers to evaluate and monitor their programmes and disseminate findings. A webbased ‘knowledge library’ has also been developed as a reference source for
stakeholders.
Departmental Expenditure
This component funds staff at the Ministry of Health to implement HEHA. In 2007/08
the HEHA team consisted of 14.5 FTE permanent staff and 1.6 FTEs fixed term
employees. Prior to 2006 this funding, listed as MoH HEHA capability, was considered
separate to the funding allocated to HEHA interventions but since 2006 it has been
included in the total HEHA budget (70) .
HEHA budget allocation
Table 31 and Figure 28 show the breakdown of the Ministry of Health’s budget for
HEHA, by area of activity, from 2006/07 to 2010/11. This excludes the PHU and Cancer
Control Action Plan funding.
Table 31:Ministry of Health HEHA budget allocation 2006-2011 as at 2006 ($ millions GST exclusive)
2006/07
2007/08
2008/09
2009/10
2010/11
Leadership
2.86
3.86
3.86
3.86
3.86
Action in School Setting
8.7
10.7
10.7
10.7
10.7
Breastfeeding
0.53
2.53
2.83
2.83
2.83
Communication
1.6
3.6
3.6
3.6
3.6
Primary Care
0.505
HEHA in the Community
(inc. Food Industry)
0.2
0.805
0.805
0.805
0.805
5.35
5.35
5.35
5.35
Monitoring & Research
Departmental
Expenditure
3.21
3.21
3.21
3.21
3.21
1.428
1.428
1.428
1.428
1.428
Total
19.033
31.483
31.783
31.783
31.783
Source: Cabinet approved funding CAB Min (06) 11/7 (25)
The increase in the HEHA budget that occurred between the 2006/07 and 2007/08
financial years resulted in increased funding for all activity areas apart from Monitoring
& Research and Departmental Expenditure.
Figure 28: Ministry of Health HEHA budget allocation breakdown by activity area 2006-2011 (GST exclusive)
191
12
10
Million
8
6
4
2006/07
2008/09
ch
pe
2010/11
Ex
&
ta
l
g
en
rin
De
pa
rtm
ito
M
on
nd
ar
Re
In
d
od
Fo
c
(in
ity
un
2009/10
HE
HA
in
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e
C
om
m
se
us
C
ar
y
Pr
im
un
m
m
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try
)
ar
e
n
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ica
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st
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e
tti
ng
Se
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ho
Sc
in
Br
ea
sh
er
ad
Le
n
tio
Ac
itu
re
0
ng
2007/08
ip
2
Source: Cabinet approved funding CAB Min (06) 11/7 (25)
In addition to the Cabinet budget data, MoH business plans also provide HEHA funding
details. The 2007/08 MoH business plan shows changes to the HEHA budget and
provides a more detailed breakdown of funding allocation and areas of activity focus; it
also incorporates the contribution to HEHA from the Cancer Control Action Plan (see ).
As HEHA has changed over time, the work programme has also changed which has
made attempts to track funding for each area of activity particularly difficult as
activities have often shifted workstreams or intervention groups, changed name, or
disappeared from the work programme all together. For example, Fruits in Schools was
listed as an individual budget item in the budget data but not in 2008/09. Table 32 and
Table 33 highlight these changes as they show a breakdown of funding by HEHA work
programmes for 2007/08 and 2008/09 as per the MoH Business Plans.
192
Table 32 Summary of HEHA work programme funding 2007/08 ($ millions GST exclusive)
Interventions
Total funding
Leadership
3.860
DHB HEHA Leadership
Workforce development Māori
& Pacific
Action in School Setting
13.651
Fruit in Schools
Health Promoting Schools
Nutrition Fund
Food & Beverage Classification
System
Train the Trainer
MoE school support
Breastfeeding
2.530
DHB Promotion Campaign
Baby Friendly Hospitals
National Promotion Campaign
Communication
5.289
HEHA Network
Youth Engagement
HEHA Branding
Health Education
Communication Plan
Social Marketing
Community Obesity
5.150
Prevention Projects
HEHA in the community
Community Projects Māori &
Pacific
Primary Care
1.694
Guidelines
Innovation Fund
Industry
0.360
Food Industry
Advertising
Monitoring, Research &
4.921
Evaluation
Monitoring & Evaluation
HRC Joint Venture
Contribution to PHI
Inquiry into obesity 7 type II
0.250
diabetes
Government ‘Walk the Talk’
(Mission-On)
Total NDE Interventions
37.705
DE Total
1.428
Grand Total
39.133
Source: MoH HEHA Business Plan 2007/08
Mission-On initiatives in italics
HEHA budget
National
Services
Cancer Control
4.400
1.778
1.333
2.000
1.689
0.460
0.889
2.860
1.000
5.000
0.745
0.095
0.300
0.750
0.100
1.680
0.430
0.070
0.180
0.290
0.630
0.150
5.000
0.345
0.160
0.200
3.210
1.511
0.200
0.250
23.445
1.428
24.873
6.86
7.4
6.86
7.4
Note: Non-Departmental Expenditure (NDE) refers to funding for services provided externally to the
Ministry of Health. Departmental Expenditure (DE) refers to funding for work conducted as part of the
Ministry of Health business.
The 2008/09 Business Plan shows the following changes in areas of activity as well as
changes to workstream names.
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Table 33 Summary of HEHA work programme funding 2008/09 (GST exclusive)
Workstreams
HEHA Sector Capability &
Innovation
DHB Leadership & Coordination
Community Action
HEHA in the Community
Workforce Development
Communication
Breastfeeding
HEHA Network
Schools & ECEs
Food & Beverage Classification
System
Nutrition Fund
District Coordinators
MoE School Support
Youth Advisory Group
Breastfeeding
Breastfeeding/Workforce
Development
Programme Development (LLL)
Social Marketing Campaign
Research, Evaluation &
Monitoring
Evaluation
Overall Strategy Evaluation
Supplement (CC funding)
FBCS process evaluation
(Mission On $150,000 08/09)
Food & Nutrition Env. Study
DHB Evaluation Funds
Monitoring
Monitoring & Evaluation Tools
(with SPARC)
Targets – survey monitoring
Veg & Fruit purchasing
Build capacity & capability
Monitoring & Evaluation tools
Research & evaluation database
Research & evaluation seminar
Research
MoH/HRC/MORST Research
Strategy
DHB Research Fund
HRC Joint Venture
Additional DE for Inquiry into
obesity & Type II Diabetes
Communication
HEHA Branding
Government ‘Walk the Talk’
Industry
Specific Food Industry Projects
Total NDE
HEHA NDE
budget
13,387,283
HEHA DE
budget
240,000
National Services
2,991,660
5,050,000
100,000
1,000,000
1,334,011
2,281,612
630,000
6,589,526
94,050
1,169,526
3,000,000
2,000,000
300,000
120,000
1,813,000
135,850
289,000
24,000
1,500,000
7,267,760
250,800
1,000,000
200,000
106,760
1,600,000
100,000
325,000
200,000
50,000
50,000
125,000
1,000,000
1,000,000
1,511,000
120,000
739,035
156,750
489,035
250,000
1,450,000
282,150
250,000
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Workstreams
Total NDE
Reducing Advertising to children
Six Industry Positions - Projects
Chip Group
Additional DE for Inquiry into
obesity & Type II Diabetes
Primary Care
Guidelines
HEHA Leadership &
Implementation
Revision of the HEHA Plan
Additional DE for Inquiry into
obesity & Type II Diabetes
HEHA Management &
Administration
Management & Administration
Total NDE Interventions
DE Total
Nutrition & Physical Activity
Specific Programmes
Nutrition & Physical Activity
Health Promotion
Sub Total
HEHA NDE
budget
200,000
900,000
100,000
HEHA DE
budget
National Services
90,000
445,000
83,600
445,000
150,000
313,500
150,000
224,000
209,000
31,841,604
2,531,049
13,360,000
18,266,000
31,841,604
2,531,049
31,626,000
Grand Total $ 65,667,304
Source: MoH HEHA Business Plan 2008/09
The following pie chart shows the percentage of total allocation by main activity area
for 2007/08.
195
Figure 29 Ministry of Health HEHA programme funding as per 2007/08 Business Plan ($ millions GST
exclusive)
Source: MoH HEHA Business Plan 2007/08
The most notable change in the 2007/08 budget was an additional $5.15 million
allocated to ‘HEHA in the Community’ to implement the HEHA Community Action
Project which focuses on engaging and mobilising Māori and Pacific communities
through DHBs to prevent obesity by improving nutrition and increasing physical
activity. It is also worth noting that while the budget for ‘Activity in School Setting’
increased by $2 million per annum in 2007/08 its percentage share of the overall
budget decreased.
Figure 30 shows the percentage of total allocation by main activity area for 2008/09.
Please note Figure 30 (2008/09) excludes Nutrition & Physical Activity National
Services funding as a breakdown was not provided in the Business Plan (unlike the
2007/08 Business Plan) and so cannot be allocated to a work stream/intervention
group. As discussed above, it is difficult to compare the budget allocation between
activity areas between years due to changes in how activity areas are described. For
example there is a change in the communication area of activity between 2007/08 and
2008/09 of $4.55 million, mostly attributed to $3.689 million of social marketing
budgets included under communication in 2007/08, but not in 2008/09.
196
Figure 30 Ministry of Health HEHA programme funding as per 2008/09 Business Plan ($ millions GST exclusive)
Source: MoH HEHA Business Plan 2008/09
Note excludes National PHU funding for Nutrition and Physical Activity Services
There are a number of other sources of funding for HEHA initiatives. As noted earlier
determining what constitutes HEHA or HEHA-related initiatives has made collecting
accurate funding details from other sources difficult. Similarly, agencies and
organisations are either directly involved in HEHA or are considered as ‘supportive’ of
HEHA, which also makes quantifying the exact resource input into HEHA difficult.
For example, SPARC, the Ministries of Education, Social Development and Youth
Development, National NGOs (such as the National Heart Foundation), local NGOs,
PHARMAC and the Health Research Council (HRC) all fund or support HEHA-related
activities. Some details of funding are readily available such as PHARMAC’s contribution
of $600,000 per annum (2004/05 - 2007/08) towards the Green Prescription initiative
and the HRC grants of $1.326 million towards three HEHA-related research projects as
part of the HRC and MoH joint venture partnership programme.
However, the key informant interviews have highlighted that many stakeholders are
participating in HEHA advisory groups for ‘free’ and that some DHBs are allocating nonHEHA funding to ‘HEHA type’ projects that were running successfully prior to the
introduction of the Strategy. In addition, some Primary Health Organisations are
funding HEHA initiatives from their Health Promotion or Services to Improve Access
capitation subsidies; this type of funding allocation is being captured by the HEHA
197
stocktake. The HEHA stocktake database, as well as data from the individual
evaluations, will help identify lower level funding sources and resource input.
The following section focuses on SPARC as it probably provides the best example of the
issue with identifying and quantifying ‘what is HEHA’, with particular reference to the
Mission-On package of initiatives. SPARC is a core HEHA partner agency (co-signatory
of the HEHA Tripartite agreement with the MoH and MoE) and as the Crown entity
responsible for sport and recreation in New Zealand it has taken the lead in a number of
physical activity initiatives, for example Mission-On. Most SPARC programmes,
however, predate HEHA, which raises an ‘ownership’ issue and their exact positioning
within SPARC can also make tracking funding streams complicated, for example ‘Green
Prescription’ (GRx) and ‘GRx Active Families’ are being expanded under the Mission-On
programme, however, on the SPARC website, Mission-On and GRx are listed separately
under different activity umbrellas.
Sport and Recreation New Zealand (SPARC)
SPARCs main programmes can be divided into two key groups, Active Living and Active
Children. One of the major programmes is Mission-On, a package of initiatives aimed at
improving the lifestyles of young New Zealanders by improving their nutrition and
getting them more involved in physical activity. SPARC is the lead agency for MissionOn.
Funding of SPARC initiatives
SPARC receives Crown funding, revenue from contracts (e.g. Ministries of Health &
Education) and funding from the NZ Lottery Grants Board. Data provided by SPARC
show the cost of the Mission-On package of initiatives as an estimated $67 million over
the four year period 06/07 – 09/10; Mission-On funding and estimated cost data are
presented in Table 34 and Table 35 shows a breakdown of the Vote Health funding
component which highlights the contribution from the HEHA budget towards MissionOn.
Table 34 Mission-On Funding ($ milions GST exclusive)
$ million
2006/07
2007/08
2008/09
2009/10
4 year Total
Vote Health
9.877
9.976
8.021
8.025
35.900
Vote Education
4.643
6.629
4.621
4.425
20.319
SPARC
Total Package
3.466
17.986
3.217
19.823
2.047
14.690
2.050
14.500
10.780
66.999
Source: Funding details for Mission-On provided by SPARC, February 2009
In 2006 the allocation of the HEHA budget ($19.033 million) was revised to include an
annual contribution from Vote Health to Mission-On. Table 35 shows the total
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contribution to Mission-On from Vote Health, 2006-2010, as well as the amount that is
funded by HEHA money (approximately 50% of the annual contribution).
Table 35 Contribution to Mission-On from Vote Health including HEHA budget allocation ($ millions GST
exclusive)
$ million
Agreed contribution from Vote
Health
Specific initiatives linked to
Mission-On funded by HEHA
money allocated in Budget 06
One-off underspends on other
initiatives also funded by HEHA
money allocated in Budget 2006
Shortfall to be met from existing
Vote Health baselines
2006/07
2007/08
2008/09
2009/10& out
years
9.877
9.976
8.021
8.025
4.600
4.800
4.800
4.800
3.950
-
-
-
1.327
5.176
3.221
3.225
Source: Ministry of Health, Health Report Ref. No. 20061898, 29 September 2006
Table 36 Estimated cost of Mission-On initiatives ($ millions GST exclusive)
Initiative
1. Improving food and
nutrition in schools
and early childhood
education services
2. Student Health
Promotions
3. Lifestyle
Ambassadors
4. Youth-branded
websites
5. Government
Walking the Talk
6. Screen-free
7. Control of TV
advertising
8. Use of television
and radio to
encourage change
9. Health Impact
Assessment
10. Expanded Green
Prescription
Programme
Branding
Campaign
Coordination
Campaign Monitoring
Estimated total operating cost ($m)
2006/07
2007/08
2008/09
2009/10
Total
6.431
7.088
6.46
5.725
25.704
0.575
0.575
0.575
0.575
2.3
0.193
0.193
0
0
0.386
4.195
4.738
2.453
2.453
13.839
0.5
0.5
0.5
0.5
2
2.0
2.0
0
0
4
0.2
0.2
0.2
0.2
0.8
0.5
0.5
0.5
0.5
2
0.24
0.60
0.60
0.60
2.04
1.4
2.78
2.75
3.3
10.23
0.1
0
0
0
0.1
0.15
0.15
0.15
0.15
0.6
1.5
0.5
0.5
0.5
3
199
Initiative
& Evaluation
Grand Totals
Estimated total operating cost ($m)
17.986
19.823
14.69
14.50
66.999
Source: Estimated cost details for Mission-On provided by SPARC, February 2009
Table 35 shows the contribution to Mission-On from the HEHA budget which is
allocated via Vote Health. However according to SPARC only initiatives 1, 2 & 7 (as
shown in Table 36) are actually part of HEHA. All the rest contribute to HEHA. Also
when the HEHA evaluation team requested evaluation details for individual initiatives it
was highlighted that SPARC objectives are considered linked to but not necessarily
aligned with HEHA objectives, which again is interesting considering the large
percentage of the HEHA budget funding Mission-On.
SPARC also contract Regional Sports Trusts (RSTs) to deliver many community based
services such as Mission-On which adds another layer of complexity to establishing
clear audit trails regarding HEHA funding.
Regional Sports Trusts
In 2004, SPARC formally recognised RSTs as key partners and contracted each of the
trusts to achieve an increase in regional levels of physical activity and strengthen
regional sport and physical recreation infrastructures.
SPARC invests in each RST using a population-based formula and also provides further
investment for targeted initiatives such as Green Prescription (GRx).
Funding for GRx is made up of RST funding in addition to money from three Primary
Health Organsitions and a PHARMAC contribution of $600,000 per annum towards the
cost of providing 12 Area Managers to deliver Green Prescription services. In 2006
Cabinet agreed to fund the expansion of GRx as part of the Mission-On campaign, with a
programme target is 50,000 adult referrals and 500 GRx Active Families by 2010. The
funding for GRx is summarised in Table 9.
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Table 37 Green prescription RST and PHO funding (GST exclusive)
Sport Northland
Sport Waitakere
Sport Auckland
Counties Manakau
Harbour Sport
Sport Waikato
Sport Taranaki
Sport BOP
Sport Hawke’s Bay
Sport Gisborne
Sport Wanganui
Sport Manawatu
Sport Wellington
Sport Tasman
Sport Canterbury
Sport Otago
Sport Southland
Sub total – RST’s
2005 - 06
86,500
20,000
144,500
98,750
125,250
221,720
8,500
30,000
96,000
65,000
30,800
7,200
105,500
107,620
122,500
68,000
48,000
1,385,840
2006 - 07
163,728
70,000
459,248
2007 - 08
200,400
70,000
627,200
256,752
281,500
66,272
179,188
166,260
65,028
87,192
36,976
205,280
137,088
189,880
108,823
119,628
2,592,843
243,120
304,960
80,000
186,100
196,020
106,020
97,920
93,720
249,040
144,000
180,400
121,940
125,460
3,026,300
Health West PHO
Otara Health PHO
Pinnacle Taranaki
Sub total PHO
64,000
20,000
84,000
107,492
130,000
21,480
258,972
144,980
130,000
21,480
296,460
1,469,840
2,851,815
3,322,760
650,359
986,400
2201,456
2,336,360
Total
Mission On contribution towards
Expanding Green Prescription
(included in these totals)
Total Green prescription Funding excluding
Expanding Green Prescription
1,469,840
*Note: Sport Auckland funding includes $20k for Auckland co-ordinator plus all funding for GRx in the
Counties Manukau Region.
Source: Data supplied by SPARC
The above tables, relating to Mission-On funding, highlight the complexity in accurately
identifying and quantifying exact HEHA funding.
Stocktake data of HEHA initiatives database
The stocktake was undertaken to capture all national, regional, and local HEHA and
HEHA-related initiatives. The principle sources of data were:
201

2007/2008 Ministry Approved Plans (MAP)

Agencies for Nutrition Action (ANA) Database

Primary Health Care Implementation Work Plan

Health Research Council

PANnet (a web based information network for providers working to improve
Aucklanders' nutrition and levels of physical activity.)
The MAPs provided information on total funding for the entire time span of the
initiative, a number of which predate the Strategy. No detail as to what was to be
funded (e.g. staff or equipment etc) was given. Where funding amounts and sources
were provided, but no breakdown between sources was provided, the amount was
divided equally between the known funders.
There were significant gaps in the funding information provided; overall there were
funding details for 437 initiatives representing 34.8% of the total (i.e. 437/1256).
While the accuracy of the stocktake funding is an issue, it is still useful in highlighting
funding allocations with regards to programme type, timing and location.
For this report, seven very large council funded initiatives (totalling just over $110
million) that focused solely on the development of parks, walkways, and cycle paths,
have been removed from the stocktake funding data as these distort the ‘physical
activity’ totals and, while contributing to the promotion of physical activity, are not
considered part of HEHA.
In light of this, we have used funding details for 430 initiatives and calculate total HEHA
funding, as per stocktake data, to be $205.6 million between 1994 and 2012. Funding
was allocated as follows: nutrition $103 million (50%) physical activity $71.7 million
(35%) breastfeeding $15.8 million (8%) and obesity $15.1 million (7%).
202
Figure 31 Stocktake $ by programme type (excluding 7 large council funded initiatives) 1994 -2012
The mean programme budget was $478,289.26, the median $61,096.50, and the mode
was $10,000.00. Figure 32shows the spread of programmes by funding.
203
Figure 32 Number of programmes by funding amount
The majority of programmes, 374 of the 430 for which we had funding details, had total
funding of less than $500,000 and 258 had funding under $100,000. Thirty four
programmes had funding over $1 million and only five had funding exceeding $10
million, they were three Mission-On initiatives, Fruit in Schools and Feeding our
Futures.
Dividing funding into the following year blocks highlighted the main activity and
funding periods: pre Strategy (pre 2002-03), early stage HEHA (pre 2005/06), the main
period of activity - in line with the main flow of funding - (05/06-08/09), and future
activity (09/10 onwards). It is interesting to note the dramatic drop in funding for
programmes that run in 2009/10 and beyond; indeed only 11 programmes are due to
run beyond 2010, nine finishing in 2011 and the remaining two in 2012. One possible
explanation for this drop is the source of data. The MAPs were compiled in 2007/08
and 2008/09. This means that they were only likely to include information on funded
programmes before 2006 if they were still running and after 2009/10 if they had
started during the periods when the MAPs were compiled.
204
Figure 33 Stocktake total HEHA funding by main activity year blocks
Funding by source is presented in Table 38 Stocktake funding by funder (1994 – 2012).
It should be noted that this may not accurately reflect the true source of funding i.e. the
MoH funding amount does not include funding devolved to DHBs or providers running
Ministry of Health contracts. It also shows SPARC as the biggest contributor at around
$90 million, $67 million of this total represents Mission-On. The full $67m for MissionOn is allocated in the stocktake to SPARC even though, as explained above, Ministry of
Health and Ministry of Education also contribute to the Mission-On package.
Table 38 Stocktake funding by funder (1994 – 2012)
Funder
SPARC
Ministry of Health
DHBs
Other
HRC
PHO
PHARMAC
Council (local or regional)
Maori Health Provider
Regional Sports Trusts
ACC
National Heart Foundation
Pacific Health Provider
NZ Transport Agency
NGOs
Amount $
90,611,216
58,845,735
25,362,326
15,408,870
5,239,960
4,063,952
3,000,000
1,545,147
704,458
266,225
200,083
176,075
77,438
51,000
47,100
% of total
44.06%
27.79%
12.33%
7.49%
2.55%
1.98%
1.46%
0.75%
0.34%
0.13%
0.10%
0.09%
0.04%
0.02%
0.02%
205
Asian Network
Ministry of Youth Affairs
38,248
26,530
0.02%
0.01%
Looking at the geographical spread of funding, the stocktake recorded funding by DHB
but also listed separately those programmes that ran nationwide and in more than one
region (multiple region). Funding for nationwide programmes totalled $123 million
and for multiple regions $21 million. Figure 7 presents total funding by location (DHB)
excluding nationwide and multiple region programme funding.
Figure 34 Stocktake total HEHA funding by DHB region (excluding nationwide and multiple region
programme funding)
Counties Manukau DHB had the highest total HEHA budget of just over $12 million
followed by Lakes, at around $10 million, and then there was a relatively big drop to the
third biggest budget in Auckland DHB at around $5 million.
The highest HEHA budget per head of population as shown in Figure 9 was in Lakes
DHB, which has a relatively small population of 102,000 and the second highest HEHA
budget after Counties Manukau. However, three programmes, all MOH funded, account
for most ($6.25 million) of the $10 million recorded as spent at Lakes DHB. The three
programmes are listed as: ‘Health Promotion Services’($4.395 million) provided by Toi
Te Ora, a provider of public health services that influence environments to protect and
promote the health of the population and reduce inequalities in health status; ‘Fruit in
Schools’ and ‘Health Promoting Schools’ ($0.388 million) also provided by Toi Te Ora;
and ‘Health Promotion Services’ ($1.466 million) provided by the National Heart
Foundation to promote the key HEHA nutrition messages. Toi Te Ora provide services
206
for both Lakes and Bay of Plenty DHBs so the programmes listed above may actually
cover both districts.
Total budget by population is shown below in Figure 35, excluding $21 million for
multiple region programmes.
Figure 35 Stocktake total HEHA funding by DHB region per head of DHB population
Other key stocktake categories
The following set of charts shows general funding allocations to key categories recorded
by the stocktake. As mentioned earlier most programmes have more than one setting,
target population or expected outcome etc so for this exercise funding was divided
equally and allocated to each where applicable.
Programme outcome
The stocktake recorded expected programme outcomes, as described in the HEHA
Strategy in line with the key principles of the Ottawa charter and additional HEHA
specific outcome areas of communication, monitor research and evaluate, health and
physical activity workforce development, and strengthening sector collaboration.
‘Creating Supportive Environments’ is the programme outcome associated with the
207
most funding at $42.585 million. ‘Strengthening Sector Collaboration’ had the least at
$2.302 million (Figure 36).
Figure 36 Stocktake total HEHA funding by identified programme outcome
Programme setting
Funding associated with programme setting is highest in those set in the community
and schools, especially primary schools (Figure 37).
208
Figure 37 Stocktake total HEHA funding by identified programme setting
Target population
Funding associated with programmes’ target population is highest for those focusing on
child and family/whānau followed by a close grouping of low socio-economic, Māori,
Youth and Pacific Islander target populations (Figure 38).
209
Figure 38 Stocktake total HEHA funding by identified programme target population
Programme targets
Programme targets focused on either increasing healthy activities or practice, such as
increasing breastfeeding and the intake of fruit and vegetables or decreasing unhealthy
intakes or behaviour. Funding associated with increasing healthy eating and physical
activity targets is almost identical at $50.845 million and $50.820 million respectively
(Figure 39).
210
Figure 39 Stocktake total HEHA funding by identified programme target outcome
Environment outcomes
Funding associated with environment outcomes is as shown in Figure 40. This reflects
funding by ‘programme type’ (as shown in Figure 39 above) which is to be expected as
outcomes will be in line with the focus of the programme.
211
Figure 40 Stocktake total HEHA funding by identified programme environment outcome
Reconciling budget with stocktake data
Ideally a reconciliation exercise would be carried out comparing the stocktake funding
data with the budget data and in a few cases this has been possible, for example
Mission-On total funding reconciles perfectly as does HRC and PHARMAC funding.
Apart from these few exceptions, attempts to reconcile the stocktake and budget data
are not possible as budget data groups funding according to workstream/intervention
groups while the stocktake records funding at the individual programme level. Only
Mission-On and Fruit in Schools funding have been listed individually in the budget data
(although Fruit in Schools is no longer broken down to the individual level in the
2008/09 Business Plan budget data).
The stocktake funding data can still be used, however, to highlight omissions within the
budget data. For example, the following funders are assumed not to be included in the
budget data: ACC, Asian Network, Councils, NZ Transport Agency, and the Ministry of
Youth Affairs – the total contribution to HEHA programmes from these funders is
$1.861 million (see Table 11). In addition, there is non Mission-On SPARC funding of
$23.012 million that is also considered missing from the budget data as well as some
funding from other sources which totals $9.018; so a total of $33.892 million can be
added to the total HEHA funding table below. As mentioned earlier the MAPs reported
some programme start dates as early as 1994 and the $33.892 million was initially
analysed as per the year blocks used in figure 6 so has been allocated as follows to fit
the main HEHA timeframe; (pre 02/03) and (pre 05/06) is allocated to 2005/06,
212
(05/06-08/09) is divided equally between 2006/07 – 2008/09 and (09/10 onwards)
total to 2009/10.
Table 39 Total HEHA funding 2005 – 2010 ($ million GST exclusive)
Source
2005/06
HEHA Budget
Cancer Control
General Nutrition & Physical Activity
2006/07
2007/08
2008/09
2009/10
#
#
*
+
19.033
7.2#
7.9
13.211
#
31.483
7.9
*
#
7.9
17.818
3.217
*
SPARC (contribution to Mission-On)
3.466
Ministry of Education (Vote Education
contribution to Mission-On)
4.643
*
6.629
^
1.055
HRC
0.6
0.6
0.126
^
++
Other HEHA funding as per stocktake
8.722
Total
29.859
*
15.598
*
PHARMAC (contribution to GRx)
7.740
++
60.035
7.740
*
40%
38.8
12%
83.280
25%
10.780
3%
*
20.318
6%
3
1%
^
4.929
2%
++
33.892
10%
76.849
327.657
7.9
19.076
*
+
17.576
2.047
2.05
*
4.621
*
4.425
^
0.989
^
1.704
0.6
++
76.442
7.740
+
*
0.6
++
84.470
% of Total
132.658
40.646
*
0.6
1.055
41.496
Total (million)
1.949
Data sources:
* Health Report: 20090031
# Progress on implementing the HEHA Strategy 2008
^ HRC website and stocktake database
+ HC06-27-2-7 Budget 2009 & line by line review of Vote Health Annex 3 'HEHA Baseline funding totals 48.546'
and reduction in PHU funding of $1.5m
++ Stocktake database funding assumed not to be in budget data
Please note that budget data for ‘general nutrition and physical activity’ (i.e. the PHU
funding) are not available for 2009/10 so we have used the 2008/09 figure minus $1.5
million which is a ‘reduction in public health unit funding’ as per the Budget 2009 line
by line review (71).
The following charts highlight total HEHA funding by high-level funder and by year.
213
Figure 41 Total HEHA funding 2005/06 – 2009/10 by funding agency
Total HEHA funding
45
40
35
30
25
20
15
10
5
0
HEHA Budget
Cancer Control
General
SPARC
Ministry of
PHARMAC
Nutrition &
(contribution to Education (Vote (contribution to
Physical Activity
Mission-On)
Education
GRx)
contribution to
Mission-On)
HRC
Other HEHA
funding as per
stocktake
Figure 42 Total HEHA funding 2005/06 to 2009/10
Total HEHA $ by year
90
84.470
80
76.849
76.442
70
60.035
Millions
60
50
40
29.859
30
20
10
0
2005/06
2006/07
2007/08
2008/09
2009/10
Conclusion
214
Using the budget and stocktake data we conclude that between 2005 and 2010, HEHA
and HEHA-related activities are estimated to have had a high-level funding allocation of
$328m.
This equates to $77.26 dollars per head of the population over 5 years or $15.45 per
person per annum. We can also surmise that, while funding was allocated to a wide
range of areas, it was predominantly allocated to nutrition and physical activity
programmes, in community and educational settings, with a child and family/whānau
population group focus.
Resources: Staffing
Another way to determine resource input into HEHA is to look at the number of FTEs
employed to implement and coordinate HEHA, as well as the number employed to
provide HEHA services. Table 40 provides a breakdown of FTEs by DHB and HEHA
staffing levels at the MoH i.e. FTEs for the implementation and coordination of HEHA
services. Two FTEs in each DHB were directly funded by the Ministry of Health through
Crown Funding Agreements; usually a HEHA Project Manager (from January 2007) and
District Coordinator (from January 2008). Funding for the District Coordinators ceased
from June 2009. Any additional positions were at the discretion of the individual DHB.
As the table shows, there were an additional 15.6 positions funded by DHBs relating to
HEHA. The cost of these was unknown; but if each is supported at the same funding
levels as set out for the Project Manager positions, i.e. $136,190 (Letter from MoH to
DHB Chairs and CEOs, 6 October 2006, Re: CFA variation for HEHA) (including working
expenses as well as salaries), this adds an additional $2.12m to the funding supporting
HEHA initiatives.
The MoH HEHA team was a multidisciplinary team headed by a programme manager
with team leader and business management support. Using FTEs to accurately establish
resource input into HEHA, however, would need to include details of new staff
employed by the individual HEHA initiatives (this data is captured in some of the
evaluations of individual initiatives, but not all initiatives have been formally
evaluated), and it would also need to reflect staff time allocated to HEHA activities from
other agencies and organisations such as SPARC and the National Heart Foundation.
215
Table 40 FTEs employed to implement and coordinate HEHA
Region/DHB
HEHA FTE
Northland
2.00
Auckland
3.00
Waitemata
3.40
Counties Manukau
3.00
Waikato
2.25
Taranaki
3.00
Tairawhiti
2.50
Bay of Plenty
3.10
Lakes
2.65
Hawkes Bay
2.00
Whanganui
2.00
MidCentral
2.00
Wairarapa
2.00
Hutt Valley
2.30
Capital & Coast
2.00
Nelson-Marlborough
6.00
Canterbury
2.50
West Coast
4.90
South Canterbury
2.00
Otago
2.00
Southland
3.00
Ministry of Health Permanent HEHA team 14.30
members
Ministry of Health HEHA Fixed Term 2.60
Employees
Total
74.50
Source: MoH HEHA Business Plan 2008/09 & data supplied by the HEHA Sector Capability & Innovation
Directorate February 2009
Funding and Value-for-Money: The Key Informants’ Perspectives
First key informant interview round
A number of economic-focused questions were included in the wider ranging key
informant interviews that took place between January and April 2009. These questions
focused on funding sources, the initiatives funded, sufficiency of resources, and whether
HEHA is producing value-for-money.
In relation to the question around whether HEHA is providing value-for-money, the
responses were generally positive although there was an understanding that this was
very much based on the potential of HEHA, as it is recognised that it would be some
time before clear measurable impacts will be seen. But across a number of agencies it
was felt that the Strategy would offer value-for-money. The following comments are
representative of the main issues raised:
216
If we weren’t doing this, then we’d have to be doing something else in this vein, and
I don’t know what else we would do. If you look around the entire world, no-one has
got the magic bullet, and it seems to me this is, both the process they’ve gone about
to design what they’re doing, and the way they engage with people and get
feedback on what they’re doing, and the variety of the approaches are all recipes
for success. They’re the best things you can do without knowing what ‘the’ answer
is.
I think that the surveys are showing that we are making an impact for the money
that we spend and in particular we compare ourselves internationally I think we’re
one of the only countries who can show a national slowing of the obesity growth
rate
I think generally speaking it is [producing value-for-money]. The difficulty is
measuring the value.
We’re actually constrained about where we can put the dollars, so we have to
assume that the Ministry has done the intervention logic work.
It was acknowledged that there was a risk that HEHA would not work, but it was also
recognised that the risk of doing nothing was far greater, given that the obesity problem
would continue. Spending money now to prevent the burden of disease that will
otherwise accrue from diabetes, heart disease, cancer etc. “So I don’t see there’s a lot of
choice and I do think it’s a sensible and wise investment.”
Some respondents noted that there may be particular initiatives which have not worked
and where funding could be reinvested. One key informant felt that the HEHA team in
the Ministry of Health and project managers in DHBs were a waste of funding, and they
would have liked to have seen the funding to directly out to NGOs and community
groups, who were already doing the work on the ground with little resource. Another
informant raised some concerns over the school toolkits, as they felt that schools did
not always know they had been sent them, and the informant doubted the schools used
them as intended. Some informants also raised the issue of duplication of activities
between the MoH and DHB and between some DHBs and NGOs, eg projects being
evaluated twice.
In addition to the value-for-money question the key informants were asked specifically
about funding, its adequacy, about any additional sources of funding that have been
used, and its security.
In most cases funding was seen as adequate or at least matched to existing capacity and
capability. However, some of the NGOs would like more funding, it was felt there were
some areas where additional funding could be used (eg walking and cycling initiatives,
more physical activity initiatives amongst the priority populations) and some concerns
were raised over the need for government departments to find the funding within their
existing budget allocations.
217
Some respondents commented on the amount of time needed for the establishment
phase and to build capacity. Some DHBs stated that they contributed their own
additional funding to HEHA-type work while others reported having no access to other
funding beyond that allocated by the MoH. As for the security of funding, many felt that
there was little or “no security whatsoever” and went so far as to say that in order to
maintain programmes a separate funding stream was needed to prevent funding being
“lost” other services. The potential damage that withdrawing funding from community
projects could have on working relationships was also a concern for some.
The allocation of resources was also discussed. Key informants noted the initial
difficulty in identifying what works in relation to HEHA, given the lack of evidence on
this. One informant noted that there is a need to rationalise as the evidence-base
improves and to focus on what works. Priorities for funding were noted to have been
determined in part by the ‘Start Here’ list in the Implementation Plan (8), partly by the
directives of Mission-On, and partly by the actions that fitted under the Cancer Control
Strategy and its funding. The HEHA business cases were seen generally to be pretty
robust by the Treasury, which also acknowledged the focus on trying to achieve and
evaluating value-for-money.
One Ministry of Health key informant did not consider it is efficient to have two HEHA
funding streams (through Crown Funding Agreements with DHBs and to Public Health
Units), and “DHBs don’t like it either because they have money coming in from different
streams with different accountabilities and mechanisms etc.”In general, HEHA is seen as a
pretty prescriptive process for DHBs with the Crown Funding Agreement setting
directions, including the targeting of priority groups, and with heavy reporting
requirements. Some money to DHBs has been allocated on a population basis, and some
per DHB (e.g. 1 project manager and 1 district co-ordinator per DHB regardless of its
population size). The allocation of one District Co-ordinator per DHB has been a
particular issue for those working in a DHB that covers a large geographical area with a
high number of educational settings as they are very much disadvantaged compared to
those DHBs with small populations. Some DHBs also have much larger Māori
populations than other areas but do not get much more funding.
One DHB Funding and Planning key informant also commented on the difficulty at times
of being “piggy in the middle” with the Ministry approving funding (such as for an
evaluation), but the DHB then having to manage that. They considered either the
Ministry should manage such contracting itself, “or else give us a pool of funding and say,
‘This is how much you’ve got for evaluation. You guys manage what you want to do and
how you want to do it.’”
Other government agencies are seen to be funding according to their own priorities
which may have some overlap with HEHA, but which are not driven by HEHA. It was
also highlighted that some had experienced difficulty with working across government
agencies and with shifting money between them even when there’s a willingness to
share resources, given the need to go back to Cabinet to get approval for re-allocations
of funding.
218
A large number of respondents said that they would like to have more flexibility in
determining their own spending priorities and would also like more consultation with
the MoH over funding decisions and priorities. One DHB informant considered it is
important that HEHA funding remains “tagged” to avoid it being absorbed into DHB
clinical services. On the other hand, another DHB informant said, “Keeping it ring-fenced
as a HEHA initiative I think may restrict it going forward. I’d like to see… [funding] rolled
into our PBF budget going forwards…[to] bring that collaborative support to other areas
of service planning.”
One DHB key informant commented on gains through working collaboratively and
sharing resources.
People were working in their own wee patch. Now those silos have broken down
and that’s because of HEHA. And people are more accepting of working together
and sharing resource and looking together for local solutions. A lot of money as
gone into this Strategy but I think it has saved money as well in a lot of areas and
resources have been used more effectively.
Another DHB informant added, “If we pool resources, than often you can do something
that on your own you can’t.”
Some Pacific participants are of the opinion that if there is more money, the focus
should be on primary health care given that the link with the DHBs has been established
through HEHA initiatives. Some policymakers see this link as a perfect opportunity to
roll HEHA into primary health care initiatives. There also some strong views that
injecting funding into primary health would probably work for Pacific communities.
This is because Pacific people have the highest enrolment of 98% in all the ethnic
groups within PHOs. And by doing this, the non-Pacific PHOs will engage more with
Pacific communities.
There is agreement from Pacific policymakers that HEHA has been a catalyst for
implementing community initiatives such as nutrition and physical activity
programmes, workforce training on nutrition, sports, church events and so forth.
However, while there are some views suggesting that HEHA has been a catalyst, there
are strong opinions from policymakers that Pacific people themselves make HEAH
actually happen. Some policymakers said that the downfall in HEHA is when the
funding is stopped and this is a concern for Pacific policymakers because they do not
want Pacific people to see HEHA as a one-off. In this instance, it is crucial that on-going
funding is continued and programmes are being monitored to measure the effectiveness
of HEHA.
Policymakers also noted that HEHA has being a catalyst for the Pacific workforce and
the younger generation to consider health as a career as reported in “My niece and
nephew talk about becoming a doctor or working within health after seeing the current
problems with Pacific people and they want to address that.”
Second key informant interview round
219
As described earlier, a smaller and more focussed second round of key informant
interviews took place between September and November 2009. The second round
interviews were specifically focused on value-for-money, informed by a PBMA method.
As discussed under methods, the interviews proved to be of limited value for identifying
specific programmes or projects where consideration of marginal gains or opportunity
cost could be used to inform future resource allocation. Having said this, some useful
data emerged and a summary of information related to programmes and projects is
provided below.
To provide context for considering key informant responses in the second round
interviews, it should be noted that between the first and second round of key informant
interviews, the following changes have been made to the nationally available funding of
HEHA related programmes:
 The school Nutrition Fund and District Coordinators funding has been cut
 There has been a reduction in the Communications Fund for DHBs
 The availability of funding for evaluation has been reduced
 Mission-On has ceased, including: end of school focussed initiatives, (including
removal of the National Administration Guideline requirement for schools to
have only health food available for sale, reduction in Push-Play funding,
cancelling of the Green Prescription enhanced programme)
 There has been a reduction in nutrition and physical activity school curriculum
support provided by School Support Services
 DHBs were instructed not to make any HEHA related funding commitments past
30 June 2010
 PHU funding for nutrition and physical activity has reduced.
The decisions to end or reduce the funding of above listed programmes was due to a
change in policy which re-prioritised some of the HEHA funding to other health
services. . The key informants interviewed in the second round had no or very limited
ability to input into these decisions. It is not known on what basis decisions were made
to change funding allocations at a national level. From Ministry of Health reports
related to the funding changes, much of the budget saved from the above cuts has been
transferred to the Kiwisport initiative.
No DHB or PHU informant identified an ability to redirect funding to replace Ministry of
Health funding where budgets had been cut. In addition to the DHBs all feeling under
financial pressures generally, the emphasis on elective surgery was identified by a few
key informants as limiting the opportunities for DHB-directed action in population
health areas.
The timing of impacts resulting from programme budget cuts may be felt differently
across different DHBs. For example, several DHB informants described retaining the
school-focussed District Coordinator positions past 30 June 2009, when the Ministry of
Health funding for these positions ceased. In all such cases the District Coordinators
were being funded temporarily through carry forward of previous Nutrition Fund and
220
salary underspend. In most cases the District Coordinators were set to finish before the
end of 2009.
Making value judgements
The programmes and activities that informants valued most were tied into their
understanding of their local nutrition and physical activity related population health
needs. As identified population health needs vary between DHBs, assessment of
programmes that could be cut or retained differed between informants across DHBs.
For example, four informants identified Māori health and nutrition as priority
population health needs, with the Community Action Fund highly valued for this
purpose.
As one informant said:
… it would be similar to whatever our strategic direction was at the time … One of
our strategic priorities are [sic] improving Māori health … and also … depending on
what the requirements of our [Government] funding agreements and what we
would be assessed on. We have certainly had, with the new government, a swinging
of the pendulum … So we would probably be looking at programmes that have
more of a physical activity component than we did beforehand …
Programmes to retain
Eleven of the 20 informants were able to suggest specific programmes or areas of action
they deemed as most important to retain. Several informants stated that they could not
identify programmes to retain without a thorough prioritisation process that would
consider programmes against identified population health needs.
Of the informants that identified programmes or programme areas as most important to
retain, these were described as:
 Community Action Projects
 Breastfeeding
 Action within schools (coordination, nutrition fund, food and beverage
classification system and National Administration Guidelines)
 Leadership and coordination
Even if not explicitly identified as a priority programme to retain, almost all informants
expressed positive views on the changes achieved in the education sector, and therefore
gave support for continuing the nutrition fund and education coordinator. One
informant suggested that in their DHB, 12 months more funding would likely see many
of the changes within schools become sustainable with minimal ongoing funding. The
sustainability of initiatives (the ability to reduce funding and/or support with the
programme continuing) was noted by most informants as an aim, although few
indicated that initiatives had yet achieved the progress needed for sustainability.
One informant described the advantage of the Nutrition Fund in the following way:
The Nutrition Fund was an attractive package for schools to take on and develop
their own health policies and provide canteen information and all that kind of stuff.
221
Already we’ve now seen that there’s greater difficulty getting the buy-in from the
early education centres and the schools as a result of that [removal of the Fund].
Another informant suggested that not all activity in schools might cease, but did suggest that
nutrition would become less of a priority for schools:
There is still going to be the Health Promoting Schools and the Fruit in Schools.
With the NAG [National Administration Guideline Five] change, reverting
somewhat, it’s almost not a core thing for schools to be focused on. I think some of
it might just get lost.
A few informants noted the importance of regulatory and legislative changes, such as
the NAG 5 in schools, to support DHB level initiatives.
Almost all DHB informants identified the education District Coordinator as providing
good value in engaging with schools, managing the Nutrition Fund and providing
additional capacity within the HEHA team. One DHB did not support the Nutrition Fund
continuing as a priority, but did consider the coordinator role as important for building
capacity within the education sector to improve environments and address nutrition
issues. Two informants did not highly value the District Coordinator, but suggested that
the local arrangements of how their particular Coordinator worked could have been
improved.
The Community Action Fund was identified by five informants as important to continue.
The reasons given for continuing the Community Action Fund centred on addressing
inequalities in nutrition and physical activity outcomes, and addressing identified needs
in Māori health.
As one informant stated:
… if you can do it at that grassroots level, that is where changes will be sustainable
over the long term. That’s why I think the community action project is successful
and has had good engagement from our Māori communities …
A few informants who did not explicitly identify the Community Action Fund as a
priority to retain, did identify Māori health needs and inequalities as priority areas for
action, without identifying initiatives to address these. Several informants also
identified funding to evaluate community programmes as important, whether this was
through the evaluation fund, or by allocating part of the Community Action Fund to
evaluation activities.
The Community Action and Nutrition Funds were also identified by a number of
informants as helping to stimulate collaboration between local agencies. This echoes
some comments concerning collaboration made in the first round of stakeholder
interviews. As one informant said:
[There is] not a lot of reason to get together and collaborate if you can’t make stuff
happen and to make stuff happen you generally need to have a little bit of resource.
222
Three informants identified building infrastructure and workforce capacity to deliver
HEHA programmes as important for their DHB. As a result the leadership and
coordination funding was identified as most important for generating momentum
towards achieving the HEHA Strategy goals.
Three informants identified the Green Prescription enhancement as important. One
informant described how the Green Prescription enhancement complemented
Community Action Projects, by taking Green Prescription into communities. Another
suggested that Green Prescription was a link between primary care and community
based initiatives, and described how their DHB had planned to put additional money
into Green Prescription enhancements, until the national programme was cut. One
informant described Green Prescription as important in the following way:
… it’s just moved to a model within our PHO and it’s working very well and linking
with other organisations very well. So I can see a range of opportunities for
collaboration and linking with other organisations and linking to Green
Prescriptions. It’s also targeting Māori very well at the moment and links very
closely to our Māori Community Action project around physical activity.
Action to increase breastfeeding rates was identified by three informants as important,
both to meet identified needs in their communities and also as a programme that can
achieve significant health benefits with relatively little resource.
Breastfeeding is about the need of our community and the gains from very little
money really. That is one programme that has been received very well from the
community and it’s been strongly indicated that that one programme would be a
really popular one to keep going.
Programmes to cut
Most informants were reluctant to identify a whole programme area to cut. Four
informants suggested that there could probably be marginal cuts across all areas. Two
informants identified communications budgets as useful, but not vital to the
programme. Two informants identified some social marketing activities as areas to cut,
due to a mixture of perceived value of these activities in achieving HEHA Strategy goals,
and to reflect stated government priorities. Social marketing activities included
websites, radio and print advertising. As with the discussion of communications
activity more generally, these activities were seen as adding value to other areas of the
HEHA work programme, rather than having a significant impact by themselves. One
informant said:
Certainly social marketing’s not high on the agenda nationally, so obviously we
would take that into consideration.
One informant was not in favour of Community Action Fund small grant rounds, and
suggested the money could be more effectively targeted at specific areas identified as
needs within their communities (and build on existing programmes/providers).
Two informants suggested that savings could be made by rationalising the activities
undertaken by the DHB and Public Health Unit. While not necessarily seen as an area
for budget savings by other informants, the cross-over between activities of PHUs and
223
other organisations was identified as an area for improvement by several informants.
Work with schools and workplaces were particularly identified as examples where
cross-over had been an issue. For instance, one informant said:
[The HEHA Programme Manager and District Coordinator positions were directed
to] … sit in a DHB, we didn’t have a say in that. There were PHUs already charged
to do quite a lot of that work, … There’s other things that couldn’t have been done
sitting it in PHUs. So I still think there is a bit of duplication in the contracting
there.
One informant suggested that programme areas yet to have any activity undertaken in
their DHB (such as breastfeeding) could be cut without losing ground already gained. In
a similar vein, two informants suggested some specific projects currently in early
phases of working with local councils or industry could be cut without affecting the
overall HEHA programme momentum. However, informants suggested that in the
longer term these programme areas in early stages of implementation (working with
councils, industry and increasing breastfeeding rates) were important areas for action
in achieving the HEHA Strategy goals.
Impact of budget/programme cuts on achieving HEHA Strategy goals
There was a general sense from informants that longer term achievement of HEHA
objectives would be reduced by current funding cuts. As one informant said “ … HEHA is
not a short term strategy. You don’t expect to see changes in six months for example”.
Most informants stated that valuable gains had been made in the education sector,
through District Coordinators, the Nutrition Fund, and less commonly mentioned Fruit
in Schools and Public Health Units. Several informants suggested that the gains made in
schools would at worst be lost, or at best not be built on or consolidated in the longer
term.
A few informants suggested that further funding cuts would likely impact more severely
on achieving HEHA strategy goals. One informant stated that with further cuts they
“just couldn’t afford to continue” with their HEHA programme. This sentiment was
echoed by another informant who stated, “I think if we got any further cuts to HEHA we
would be fundamentally looking at the programme. There’s not a lot else to cut”. In
contrast, two informants suggested that if all HEHA funding was cut, they could
maintain some HEHA related activity due to gains in community capacity to undertake
nutrition and physical activity related actions, and continuing capacity with PHUs.
A few informants particularly noted the negative impact that removing funding could
have on Māori communities. One informant believed HEHA had promoted significant
community development and up-skilling within Māori communities, and was concerned
they would not have access to alternative funding to sustain initiatives. This sentiment
was echoed by three other informants. Three informants described the Community
Action Fund as an effective way of engaging Māori communities to make changes to
food and physical activity environments, relevant to the particular communities.
224
Conclusions
One of the key evaluation questions for the evaluation is, has the HEHA Strategy and its
implementation resulted in value-for-money? This first report focuses on identifying
the high-level funding provided for HEHA and the early views of key informants on
whether the Strategy and its implementation are likely to result in value-for-money and
the marginal benefits of HEHA related programmes and projects.
In identifying the high-level funding allocated to HEHA, we firstly need to understand
what HEHA is and which initiatives it comprises. As this is not always agreed amongst
key informants, we identified a number of alternative ways of thinking about HEHA.
Comparing budget with the stocktake funding data has proved difficult due to issues
relating to completeness, accuracy, duplication and the general incompatibility of the
two data sets. While the accuracy of the stocktake funding is an issue, it is still useful in
highlighting funding allocations with regards to programme type, timing and location
and has highlighted omissions within the budget data.
From this, we conclude that between 2005/06 and 2009/10 HEHA-related activities are
estimated to have had a high-level funding allocation of $328 million. We surmise that
funding was predominantly allocated to nutrition and physical activity programmes, in
community and educational settings, with a child and family/whānau population group
focus.
Key informants were also asked about their current views on whether HEHA would
offer value-for-money, and about a number of funding-related issues. The responses
were generally positive although there was an understanding that this was very much
based on the potential of HEHA, as it is recognised that it would be some time before
clear measurable impacts will be seen. But across a number of agencies it was felt that
the Strategy would offer value-for-money. The only major concern raised about
possible waste of resources, was the issue with duplication of services, which would be
less of a problem with improved communication. Other key points raised by the
informants focused on the general adequacy of the funding made available so far, the
time needed to begin implementing the Strategy, and present concerns over a lack of
security for HEHA funding. Key informants commented that, in general, HEHA is seen
as a pretty prescriptive; DHB key informants desired more local flexibility in
determining their own spending priorities and more consultation with the MoH over
funding decisions and priorities.
When considering which HEHA related programmes or projects could be cut or should
be retained to maximise efforts to achieve the HEHA Strategy goals, there was limited
data of use. During the course of key informant interviews it became clear that limited
evaluation evidence combined with differing population health needs made identifying
the perceived value of programme difficult for key informants. It also became clear that
the marginal gains of programmes appear to be closely linked to institutional
arrangements for delivering programmes. The data collection method used for this part
225
of the evaluation was not designed to collect detailed institutional arrangement data.
Finally the s reprioritisation of some of HEHA funding to other health services made it
difficult for key informants to the value of competing programmes.
Having said this, some indications of the programmes most valued by key informants
were gained. Valued programmes included: the Nutrition Fund and education District
Coordinators; the enhanced Green Prescription programme; the Community Action
Fund to address health needs within Māori and Pacific communities; breastfeeding
initiatives; and leadership and coordination of HEHA programmes at DHB level.
Resources may be able to be redirected towards the highly valued programmes through
small marginal cuts across the range of programmes, particularly communications;
improving targeting of programmes to community health needs; and reducing
duplication between programmes.
Recommendations

That the Ministry of Health continue reporting on the funding allocations
provided for HEHA, in order for the evaluation to track the high-level funding
allocations.

That the Ministry of Health continue reporting on full time equivalents at DHBs
and the Ministry of Health working on HEHA.

That the Ministry of Health clarify the ‘HEHA-funded’ and ‘non-HEHA funded’
categories in the MAPs.

That all organisations involved with HEHA continually assess the effectiveness
and value-for-money offered by the various initiatives, reallocating funding
where necessary, in order to improve value-for-money.

That the Ministry of Health increase flexibility with DHBs and other
organisations to allocate funding to best meet the needs of their community.

That all organisations involved with HEHA recognise that not all organisations
receive funding to engage in Strategy development and implementation such as
HEHA and encourage the allocation of funding (perhaps based on State Services
Commission regulations) to support organisations where appropriate.
.
226
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