In the 10-part series What's the Plan? The Herald's political and specialist reporters examine the big issues facing New Zealand and how the main political parties plan to deal with them. Here, Nicholas Jones compares health policies.
Surviving a global pandemic has been added to hip replacements, mental health and the quality of cancer care in Election 2020 health policy.
Covid-19 has dominated voters and politicians' attention, including responding to community cases and keeping public confidence in safeguards like community testing and border controls.
Another looming challenge is preparing for a possible vaccine breakthrough. Securing enough stock and rolling out the biggest immunisation campaign in our country's history will be no small feat, evidenced by the immunisation gaps that fuelled devastating measles outbreaks.
There's also an enormous elective procedure backlog caused by the lockdown - National policy is to guarantee elective surgery within four months of a decision to treat, which is currently expected of DHBs but sometimes not being met.
Nationwide about 153,000 surgeries and procedures, radiology scans and specialist appointments need to be done to catch up from the first lockdown alone, and Budget 2020 provided a one-off boost of $283 million over three years to clear that backlog.
Prior to Covid, the Labour-led Government focused on helping DHBs match booming demand caused by a growing and ageing population, sickening with chronic and often obesity-related disease.
A common refrain - disputed by National - was this was made harder by nine years of underinvestment by the previous National Government.
Many health buildings are in bad condition, with an estimated fix-it cost of $14 billion over the next decade. A series of projects have been funded, including a new hospital for Dunedin, and new upgrades are being announced on the campaign trail.
National is announcing its own infrastructure programme, including rebuilding Hawke's Bay Hospital's main block.
Big reforms set out during the last term are yet to be fully rolled out, including a flagship policy to put mental health workers in doctors' clinics.
A new cancer control agency is up-and-running and faces a huge task including to reduce regional differences in services.
National has pledged $5m a year to test more women for gynaecological cancer and fund more access to clinical trials and wants to set up funds dedicated to cancer and rare disorder drugs - criticising recent increases in Pharmac funding as not nearly enough.
Another policy is to fund "primary care navigator" roles in every general practice. Based on a United Kingdom model, such people would support doctors by allowing more time to talk to patients and follow-up appointments and referrals and do home visits.
National would also give expectant mothers a $3000 entitlement, to be used to spend on services for their baby's first 1000 days, with those with higher needs getting up to $6000. The package includes better funding for pre- and post-birth GP visits, allows parents to both take paid parental leave at the same time, and would establish a "national centre for child development" to drive research.
An extra $30m a year would go into childhood oral health under National, with other policies including a dedicated border agency, making DHBs report against a new Māori health strategy and "passing all health legislation through an inequality filter", increasing funding for cochlear implants from 40 to 100, and funding 100,000 counselling sessions for the immediate impacts of Covid-19.
National's health spokesman Dr Shane Reti has called for changes in the Covid-19 response, including making day-three managed isolation testing compulsory and recording details of people who are declined tests.
Whoever is in government next will need to decide what, if any, recommendations it will act on from a "once-in-a-generation" report on the health sector.
The Simpson report recommended slashing the number of DHBs and scrapping board member elections, new entities including a Māori health authority, greater integration between primary care (like GP practices) and hospitals, and more focus on population health.
Some health leaders aren't waiting - using the aftermath of Covid for innovation including considering prioritising Māori and Pacific patients for some elective surgeries, in recognition of decades-old and discrimination-driven health gaps between those groups and the Pākehā majority.
National opposes such prioritisation, and doesn't like the idea of a Māori Health Authority, or merging DHBs and scrapping elections.
The party would reintroduce public reporting of national health targets, which it brought in when last in power and monitors DHB performance including cancer treatment times, elective surgeries and ED wait times. Labour claimed the reporting created "perverse incentives", but National's view is such exposure helped focus spending, services and saved lives.
• Election 2020: National's health policy - more money for Pharmac, elective surgery guarantees
• Bowel cancer screening age won't be dropped for Māori and Pacific NZers, despite expert advice
• Election 2020: Political parties divided over folic acid in bread - where Labour, National, the Green Party, NZ First and Act stand
Labour will reduce the number of DHBs over the next five years.
Its $1b package of health policies includes giving every primary and intermediate student access to mental health support, and expanding the nurses-in-schools programme to all secondary schools (it's currently in decile 1 to 5 schools).
An extra $200m over four years will go to reducing waiting lists, with Pharmac getting the same funding boost.
Emergency grants for dental care for people on low incomes would be increased from $300 to $1000, and 20 additional mobile clinics would be funded to make sure all under 18s are getting free care.
Other policies include doubling funded cochlear implant procedures from 80 to 160 per year, and $20m to boost the number of Pacific healthcare workers.
Labour would also establish an Aged Care Commissioner as a watchdog over the sector, a Public Health Agency and a rheumatic fever register.
It has pledged to increase minimum sick leave entitlements from five to 10 days a year, which it says will ensure people can stay home when sick and minimise the risk of Covid-19 spreading.
One flashpoint has been the resignation of Canterbury DHB's chief executive and board members, amidst pressure on the board to rein in deficits. That's caused staff protests and worries over service cuts, but Health Minister Chris Hipkins has insisted DHBs must get back into the black - and those consistently over budget shouldn't be rewarded.
There's been little difference between the major parties on obesity measures - Labour continued National's preference to work with food and drink manufacturers to try and bring down obesity rates, something that disappointed public health experts who want direct regulation like sugary drinks taxes - a step supported by the Green Party, who also want only health food and drink in schools, and a ban on junk-food adverts during children's TV programming.
A new Greens policy that disability advocates have been crying out for is to reform ACC to cover all health and disability-related support - ending the current two-tier system where people left disabled by an accident get much greater support.
The Greens also want to extend free dental care to students, beneficiaries and superannuitants, a powerful Māori Health Agency and free doctors visits for under-18s, with a nurse in every low-decile school.
The party announced a policy to double sick leave before Labour, and says if elected to a partnership government that change would be made asap.
Drug abuse should be treated as a health issue, the Greens believe, and the party has been the driving force behind a referendum to legalise personal use of cannabis for people 20 years and older, which will coincide with the election.
NZ First progressed a number of health changes under its coalition agreement,
including free doctors visits for under-14s and re-establishing the mental health commission. An annual free health check for seniors has funding but is yet to be rolled out.
The party's 2020 campaign pledges include giving $10m over three years towards the cost of providing free counselling for young people; fully funding St John ambulance services; free dental care for people 25 and younger and SuperGold card holders; and more money for Pharmac, including a $30m rare disorders fund.
NZ First also wants a new border management agency, and for managed quarantine and isolation facilities to be moved from hotels into army bases.
Act wants an independent review of Pharmac, subsidies for more common elective surgeries in private hospitals through competitive tender, and a stand-alone mental health and addiction agency, to channel the billions in funding currently controlled by the Ministry of Health and DHBs to a greater range of contracted providers, chosen by the patient.
Other policies include slashing the number of DHBs to six, temporarily doubling Customs' funding to reopen the border "as soon as it is safe to do so", and establishing a public health service to streamline responses to future epidemics.
Act leader David Seymour's End of Life Choice Bill gives those with a terminal illness the option of legally requesting help to end their lives, according to strict conditions. The legislation has passed but isn't binding until New Zealanders vote "yes" or "no" in a referendum coinciding with the election.
The Māori Party wants an independent Māori Health Funding Authority to oversee the distribution of billions of dollars in funding, a "Whānau Health Card" which would be used like a credit card to purchase health services, and for free cancer screening to start 10 years earlier for Māori.
Spend on prevention to save lives, and money
Phillip Momberg's diabetes was getting harder and harder to control until he went on a new drug as part of a trial at Auckland City Hospital.
The 65-year-old had been taking Metformin for his Type II diabetes, but as he got older it became less effective, and his blood sugars began rising.
He was put on an "SGLT2 inhibitor" drug called ertugliflozin for two years under the hospital trial, and it had a huge effect - helping keep down his blood sugar levels.
That's critical, because having too much glucose in the blood in the long term damages nerves, organs and tissue, and risks complications including heart attack, stroke and kidney failure.
However, the trial ended last year and Momberg came off the inhibitor, which worked by helping the kidneys lower blood glucose levels.
He's back on Metformin (used in New Zealand since 1957) and his diabetes is getting worse. He already eats well and is active, and is worried he's on course to become insulin-dependent.
Pharmac has announced it is looking at funding empagliflozin, another type of SGLT-2 inhibitor, from December 1, and another diabetes drug, dulaglutide, a GLP-agonist, once it has Medsafe approval.
The Diabetes Foundation estimates 491 deaths each year could be prevented by the use of SGLT-2, and a further 99 renal replacement therapies (dialysis). Following Pharmac's announcement, it criticised making patients and clinicians apply for "special authority" to use the newly funded drugs, instead of making it standard care - saying this could mean about 200,000 diabetics miss out.
Momberg would like the next government to fund more preventative treatments, like better diabetes drugs, which would prolong life and save money overall given the huge cost of treating complications like dialysis.
He's currently splitting time between Kaiaua, near Miranda Hotpools, and Auckland, where someone special lives.
"I have a grandson who is 3, and we get along quite well. And sometimes I get quite despondent when I'm thinking how, if this diabetes doesn't get under control, it's going to affect everything else. Is that going to shorten my life? It plays on my mind all the time."
• $5m a year to test more women for gynaecological cancer, $50m per year dedicated to cancer drugs, and $5m a year for rare disorder drugs.
• A $3000 entitlement for expectant mothers, to be used to spend on services for their child's first 1000 days, with those with higher needs getting up to $6000.
• An extra $30m a year for childhood oral health, including paediatric and school dental services.
• Fund "primary care navigators" for every general practice, to spend extra time talking to patients to ensure they get the care needed.
• Ensure every person accepted for elective surgery actually gets that procedure within four months of the decision to treat.
• Increase minimum sick leave entitlements from five to 10 days a year.
• Give every primary and intermediate student access to mental health support, and expand the nurses-in-schools programme to all secondary schools.
• An extra $200m over four years to reduce waiting lists, with Pharmac getting the same funding boost.
• Increase emergency grants for dental care for people on low incomes from $300 to $1000.
• Establish an Aged Care Commissioner as a watchdog over the sector, and a Public Health Agency and rheumatic fever register.
The Green Party
• Put a levy on sugary drinks, only provide healthy food and drink in schools and ban junk food advertising during children's TV programming.
• Extend free dental care to students, beneficiaries and superannuitants, and free doctors visits for under-18s, and put a nurse in all low-decile schools.
• Establish a powerful Māori Health Agency and properly fund Māori and Pasifika community-based healthcare providers.
• Reform ACC to cover all health and disability-related support - ending the current two-tier system where people left disabled by an accident get greater support.
• Double sick leave to 10 days, so people can stay home and reduce the risk of spreading Covid-19.
New Zealand First
• Provide $10m over three years towards free counselling for young people.
• Fully fund the St John ambulance service.
• Create a new agency responsible for border management, with all managed quarantine and isolation facilities to be moved from hotels into army bases.
• Free dental care for those 25 and younger and SuperGold cardholders.
• Boost Pharmac's funding, including a $30m rare disorders fund.
• Create a stand-alone mental health and addiction agency, channelling the billions in funding currently controlled by the Ministry of Health and DHBs to contracted providers, chosen by the patient.
• Carry out an independent review of Pharmac, and subsidise more common elective surgeries in private hospitals through competitive tender.
• Establish a public health service to streamline responses to future epidemics.
• Reduce the number of DHBs from 20 to 6.
• Act leader David Seymour's End of Life Choice Bill gives those with a terminal illness the option of legally requesting help to end their lives, according to strict conditions and checks. The legislation has passed but isn't binding until New Zealanders vote "yes" or "no" in a referendum coinciding with the election.
The Māori Party
• Establish an independent Māori Health Funding Authority to oversee the distribution of billions of dollars in funding.
• Roll out a Whānau Health Card, which would be used like a credit card to purchase health services.
• Give Māori free cancer screening 10 years earlier, in recognition of the fact the disease strikes Māori earlier in life.
• Establish a Kaupapa Māori Mental Health Service.
• Guarantee that 25 per cent of all government projects prioritised through Covid-19 recovery legislation partner with hapū, iwi and Māori organisations and businesses.