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ARTICLE

A media content analysis of New Zealand’s district health board Population-Based Funding Formula Aaron N Chester, Erin C Penno, Robin DC Gauld

ABSTRACT AIM: The Population-Based Funding Formula (PBFF) has a significant impact on health funding distribution between New Zealand’s 20 district health boards (DHBs) yet is subject to little independent oversight or public scrutiny. There has been widespread dissatisfaction among DHBs with the allocation process; however, there are limited formal avenues available for DHBs and the public to discuss the PBFF. As such, the news media has become a key platform for voicing concerns. This study aims to gain a better understanding of how the PBFF is portrayed in the news media and of perceptions of funding allocations across the country. METHOD: We conducted thematic analyses of 487 newspaper articles about the PBFF, published over 13 years from 2003–2016. We then identified trends in the data. RESULTS: Typically presented in a negative light, the PBFF was commonly framed against a background of financial struggle and resultant impacts on health services and sta . The e ect of factors driving DHB allocations and the PBFF process itself were also key themes. There were significant regional and temporal variations in reporting volume, with most articles focusing on South Island DHBs and occurring during the introduction of the PBFF and at the time of the most recent review. CONCLUSIONS: The findings suggest general discontent with the PBFF model across the DHB sector and a sense that the PBFF has failed to address various challenges facing DHBs. The geographic imbalance in reporting volume suggests that frustration with the PBFF is particularly keenly felt in the South Island. Although the PBFF is a lightning rod for frustrations over limited health funding, the findings point to the need to improve transparency and dialogue around the formula and to monitor of the impact of PBFF allocations throughout the country.

ew Zealand’s Population-Based account for diseconomies of scale related to Funding Formula (PBFF) was imple- rurality, overseas visitors and unmet need. Nmented by the Fifth Labour Gov- The formula controls almost three quarters ernment on 1 July 2003, as part of major of Vote Health, the main source of funding health system reforms at the turn of the for New Zealand’s health system, making millennium.1 The Ministry of Health (MoH) it one of the single largest determinants of uses the PBFF to distribute funding among government expenditure ($11.72 billion the nation’s 20 district health boards (DHB), in 2015/16).1,2 The PBFF is reviewed by the which in turn provide or fund health ser- MoH every ﬁ ve years, with the most recent vices within their districts. The allocation review taking place in 2015 in concert with that each DHB receives is determined by the belated 2013 Census.1,2 Despite periodic the number of people in their catchment internal review, there have been calls for areas, their ethnicity, sex, age and relative a comprehensive and independent review deprivation. Adjustors are also included to of the PBFF amid concern over a lack of

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transparency surrounding the PBFF.1,3 It has spondingly, its considerable political and been argued that such a review would allow social relevance, there is a need for a greater greater public discourse around this issue of understanding of patterns and content of national interest, as occurs in other nations the media discourse surrounding the PBFF. which have greater transparency around This study aims to fi ll this gap by exploring their health funding formulae.4 how the PBFF has been represented in the Since the formula’s advent there has media throughout New Zealand for the 13 been widespread dissatisfaction among years from its introduction in 2003 through DHBs with the allocation process.5 This is to 2016. Specifi cally, this study aims to fuelled in part by considerable variations explore variations in regional coverage in fi nancial performance across the DHB of the PBFF over time and to identify key sector, coupled with growing disparities commonalities and differences in the issues in access to health services.6 These issues reported across the DHB sector. In doing are compounded by a lack of transparency so, this study contributes to a growing surrounding the methodology under- body of research surrounding popula- pinning the formula, along with limited tion-based health funding models within 1,4,13–16 formal avenues available for DHBs to New Zealand, offering insights into the express their concerns and a corresponding context, perceptions and impact of the PBFF limit on public engagement.1 Thus, media throughout the country. reporting on the PBFF provides DHBs with an important social platform to voice their Materials and concerns about how the formula is oper- ating.7–9 It is also the key avenue for the methods public to gain knowledge about a salient New Zealand print media ownership is issue which has considerable impact on the dominated by two public companies, NZME level of healthcare services they receive.9 and Fairfax, which hold a duopoly on the Since health is a key political concern market at 89.3% of circulation. Allied Press, among the New Zealand public, the PBFF a privately-owned company with a focus on has received widespread coverage in the the Southern regions, constitutes the bulk of media. However, New Zealand’s print media the remaining market share at 8.4% of circu- is dominated by regional news outlets. lation. Collectively, Fairfax, NZME and Allied These print sources tend to offer regionally Press own all of New Zealand’s major news- 17 focused views refl ecting how favourable the papers. We searched for stories related to PBFF has been to their respective DHB.6,10–12 the PBFF in the Newztext and Factiva online newspaper databases, which collectively Fragmented media coverage presents cover these major print sources. The fi rst signifi cant challenges to understanding both author led data collection and analyses with the perceived and real impacts of the PBFF oversight from the second and third authors. model across the DHB sector. The focus on regional issues means it is diffi cult to gain The search parameters included a prag- a complete perspective of the key issues matic timeframe from 1 January 2003 to surrounding PBFF and the common threads 1 October 2016. This allowed us to focus emerging with respect to health funding on the established formula rather than its throughout the country. At the same time, development or previously used formulae. media coverage has been shown to play a Our search terms were: ‘population-based key role in steering public conversations and funding formula’ OR ‘DHB AND funding perceptions of health funding decisions.6,7,9 AND formula’ OR ‘population based funding’ This in turn drives political discourse and OR ‘needs based funding’ OR ‘capitation’ OR ultimately infl uences the policy decisions ‘rural adjuster’. Our criterion for analysis surrounding resource allocation.7,9 However, was broad and included any story related to news media tends to sensationalise health the PBFF. Articles which did not specifi cally funding issues and does not necessarily mention New Zealand’s DHB PBFF were drive health policy in the direction of excluded from the study. effi cacy and pragmatism.9 We used a qualitative descriptive Given the signifi cant pecuniary impact of approach to our analysis, which focused the PBFF on the health sector and, corre- on the content of the data to identify key

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themes within the articles.18,19 Coding was 36.3% of articles. Of 487 articles, 438 were led by the fi rst author. Coding was data news articles and 49 were opinion pieces. driven with codes for each idea developed Key themes with oversight from the second and third Over the 13-year period, media coverage authors. We then reviewed these codes largely centred around four major themes: to identify overarching themes and went DHB fi nancial positions, the impact of on to discuss each of them in turn.18,20 We the PBFF on DHBs, factors affecting PBFF also recorded the DHB at the focus of each allocations and the PBFF policy process. article and the status of that DHB’s share Table 1 shows these themes and the major of Vote Health, be it increased, decreased sub-themes identifi ed in our analysis. or unstated. We recorded any attitudes expressed towards the formula, which were Financial position of DHBs gauged as positive, negative or neutral. The PBFF was typically mentioned in the The attitude assigned to each article was context of fi nancial constraints or diffi culties based on comments of key interest groups faced by a given DHB and the resultant therein, with DHBs’ comments taking impact on availability of health services and precedence over other groups (ie, if a DHB staffi ng. DHB defi cits were the most signif- had misgivings with the PBFF, yet the MoH icant factor driving media coverage on the gave a glowing appraisal, the attitude was PBFF and were mentioned in over a quarter recorded as negative). We noted which of articles. Defi cits were a common theme groups or individuals were commenting throughout the country. However, they on the formula and recorded any relevant received particular attention in the South comments therein. Island where 88.5% of articles mentioned defi cits. Discussion of defi cits was frequently Results accompanied by information regarding the share of funding or the size of budget Search results increase a DHB received, often couched The Newztext and Factiva databases held in comparison to other DHBs across the 487 articles relevant to the PBFF, published country. For example, early coverage (2004) between 1 January 2003 and 1 October 2016. of the PBFF model in The Christchurch Press The Newztext database search returned 435 noted: articles; 12 were duplicates and 113 were “Reduced funding from July will severely irrelevant, giving 310 relevant articles in squeeze an already cash-strapped Canterbury total. The Factiva database search returned District Health Board (CDHB), health bosses 197 articles; 20 were irrelevant, leaving 177 warn…despite a projected $5.2 million budget relevant articles. blowout at Christchurch Hospital—it faced Regional and temporal trends an even bigger challenge from July, when its The number of articles published about annual funding increases start to shrink. The the PBFF reduced over the 13 years, from Ministry of Health estimates that the DHB a maximum of 93 in 2003 to a low of 19 in is $42m over-funded under the new popula- 2013. In 2015, there was a sharp spike of 47 tion-based funding model. That means it will articles published. Figure 1 shows there was get a smaller share of funding over the next a clear regional bias in reporting, with the six years as other DHBs are paid more to South Island’s fi ve DHBs the focus of 78.6% catch up to Canterbury.”21 of all articles; whereas the North Island’s Likewise, more recent coverage (2015) 15 DHBs were the focus of only 21.4% of in the Taranaki Daily News prefaced a articles. The Southern DHB and its prede- comment around Taranaki DHB’s $2.32 cessors (Otago and Southland) were the million defi cit by noting that: focus of almost half (47.4%) of all articles. “Taranaki’s share of the nation’s health Correspondingly, most articles were printed budget is likely to be reduced after changes by South Island-based newspapers (81.7%). were made to the formula used to allocate the Fairfax-owned newspapers printed 56.7% money. Health funding is distributed among of articles, compared with NZME at 7.0%. the 20 district health boards (DHBs), but after Allied Press-owned newspaper, the Otago changes to the population-based formula, Daily Times (ODT), accounted for remaining four DHBs—Taranaki, Nelson Marlborough,

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Figure 1: The number of newspaper articles published about New Zealand’s Population-Based Funding Formula per district health board between 1 January 2003 and 1 October 2016.

*Otago and Southland DHBs were amalgamated to form Southern DHB in 2010.

Auckland and Wairarapa—are likely to DHBs (48.1% of articles assigned this receive a smaller share from July 1. Seven theme). The rising cost of staff wages were DHBs are likely to get an increase.”12 frequently tied to fi nancial crises faced by Impact of PBFF allocations on DHBs, which in turn were linked to budget allocations. In order to balance the books, DHBs DHBs were reported to be grappling with The impact or relationship between job cuts, under-staffi ng or cutting back health funding allocations and DHB perfor- health services. The pressure placed on mance was also a persistent theme. Health doctors due to insuffi cient staffi ng was also funding crises linked to funding alloca- cited, especially in rural areas such as South tions were frequently cited as the cause Canterbury or Ashburton. of health services being cut or stretched. The abolition or reduced funding of aged Factors a ecting PBFF allocations care services was a prominent example of Technical descriptions of the PBFF in this, with headlines such as “Knife Taken media articles were limited and, where To Elderly Services” and “Elderly Health present, tended to be presented in rela- Care Fears.”22,23 The impact the formula had tively simple terms. However, discussion on DHB staffi ng was also a major theme, surrounding the factors underpinning in particular for the Canterbury (24.7% of PBFF allocations, such as population size articles assigned this theme) and Southern and composition and their relationship

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with funding allocations were identifi ed lysed considerable discussion in the South, as issues in a number of DHBs. Population with the MoH reviews of the PBFF featuring age was cited as an issue related to demand prominently in the ODT and the Southland for health services for six DHBs, including Times. The bulk of these articles (34.1%) Canterbury, MidCentral, Southern, South were printed in 2015 and coincided with Canterbury, Nelson Marlborough and Wait- the release of the Government’s fi ve-yearly emata. With the exception of Waitemata, review of the formula. these DHBs had older populations than the Attitudes and Vote Health national average.24 Although also included Most attitudes expressed towards the as factors within the PBFF, concerns formula were negative (n=84, 96.6%). Many surrounding deprivation and ethnicity of the more antipathetic comments came appeared less frequently. Similarly, although from politicians. For example, one politician also adjusted for within the formula, unmet argued that “the government should reject need and the effect of overseas visitors this population-based funding formula that received less attention. clearly isn’t working for our communities In contrast, rurality was a commonly and fund services to the current need.”12 raised issue, particularly among South At the same time, many DHBs displayed Island DHBs. As with DHBs, political parties resigned acceptance of the PBFF’s realities, often cited rurality as an issue facing the “Board chairman Syd Bradley insisted the PBFF, with the relationship between rurality CDHB [Canterbury DHB] would learn to live and diffi culty recruiting medical staff within its new budget…”26 frequently linked to funding. An enduring The three positive attitudes all coincided opinion was that the PBFF model did not fi t with an increase in the share of Vote Health the unique needs of DHBs with large rural for the DHB concerned. In most articles areas such as the West Coast or the Southern (59.1%), the DHB’s share of Vote Health District Health Board. For example, the decreased, or there were issues with under- Southland Times wrote: funding. Most (55.2%) of these articles “King [New Zealand Labour Party Health were published in the two years after the Spokeswomen] said the current popula- formula’s introduction. In 2003, 12 (13.8%) tion-based funding formula was not providing negative attitudes were expressed towards enough funding for big rural areas such as the formula. This number decreased and the Southern District Health Board, which plateaued over time, excepting a peak (n=19, faced massive defi cits and was replaced with 21.8%) in 2015, which coincided with the a Commissioner this winter.”25 MoH review of the PBFF. South Island DHBs Population change was also identifi ed as a were the focus of most (83.3%) articles problem. DHBs with small, relatively static expressing negative attitudes towards the populations were portrayed as struggling formula. Opinion pieces contained most due to the comparatively small increases negative attitudes (55.3%), compared with in funding under the PBFF model, which news articles (13.2%). was seen as a problem confronting South Interest groups Island DHBs in particular. Conversely, rapid We identifi ed 11 key interest groups in population growth in the Auckland region the media coverage, most prominently DHBs was seen as creating a “gap” between DHBs, the MoH and politicians—both in increased demand for health services and government and in opposition (Table 2). funding allocations. In terms of volume, the vast majority of PBFF policy comments on the formula were offered A perceived lack of transparency by individuals associated with DHBs, such surrounding the PBFF model and allocation as DHB board members, Chief Executive process was discussed in 26 articles. Twen- Offi cers or Planning and Funding staff. ty-two (84.6%) of these articles mentioned Many of these comments implicated the the Southern DHB or its predecessors, formula in fi nancial woes. For example, one suggesting transparency was a particular DHB board member blamed “The board’s concern among DHBs in the South Island. funding shortfall [on] general under- Potential changes to the PBFF model and, funding and the ‘adjusters’ used in the correspondingly, DHB allocations, also cata- Health Ministry’s population-based funding

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Table 1: Salient themes in newspaper articles about the Population-Based Funding Formula.

Theme Meaning n=487 % Financial position of DHBs Vote Health share A change in a DHB’s share of Vote Health was mentioned. 153 31.4

DHB deficit DHB deficits were mentioned. 131 26.8

Impact of PBFF factors on DHBs Services stretched DHB health services were stretched or compromised in relation to funding. 104 21.3

Services cut DHB health services were abolished in relation to funding. 94 19.3

Impact on sta DHB sta were impacted (eg, job loss) by changes to funding or underfunding. 81 16.6

Doctor recruitment The recruitment of doctors was impacted by the formula. 18 3.7

Factors a ecting PBFF allocations Age PBFF and health costs were a ected by the age of a population. 71 14.5

Rurality PBFF and health costs were a ected by rural populations. 54 11.1

Population Population size and changes to that size a ected PBFF. 51 10.5

Unmet need There was a level of unmet need in healthcare stemming from PBFF allocations. 22 4.5

Ethnicity Ethnicity was an issue in relation to PBFF. 17 3.5

Deprivation Deprivation was an issue in relation to PBFF. 13 2.7

Overseas visitors Overseas visitors were a ecting PBFF. 6 1.2

PBFF policy Review Review of the PBFF was mentioned or advocated for. 40 8.2

Transparency There was concern over a limited transparency around the PBFF and its workings. 26 5.3

Abbreviations: PBFF, population-based funding formula; DHB, district health board.

Table 2: Groups commenting on the Population-Based Funding Formula.

Interested party Number of articles group Percentage of articles group commented on (n=442) commented on (n=487) * District health boards 211 43.3

Ministry of Health 77 15.8

Politicians 50 10.3

Contracted providers 23 5.2

Professional groups 18 3.6

Medical professionals 14 2.8

Patient groups 14 2.8

Other 14 2.8

Academics 12 2.5

Government (other than MoH) 6 1.2

Local body politicians 2 0.4

*Percentages do not add to 100%. Abbreviations: MoH, Ministry of Health.

method, particularly the rural adjuster, and the impact and success of health which included patient transport. They had policies, including healthcare funding.32,33,35 not kept up with infl ation and the adjuster The distribution of healthcare resources did not cover costs.”27 However, there was is of signifi cant public interest in New a dearth of explanations as to how the Zealand and is often the subject of intense formula could be improved. Phrasing also public debate.6,36 News media coverage appeared to erroneously imply that certain has previously been used to explore the DHBs’ funding had been reduced in absolute effects of variations in health policy deci- terms. On the other hand, DHB representa- sions across the DHB sector,6 lending tives also often emphasised efforts to live insights into the factors and circumstances within budgetary restrictions or refused to affecting nationally consistent provision of comment. Comment from the MoH tended health services. Viewing the PBFF through to emphasise that funding allocations were a news media lens, we sought to explore never cut and were increased annually. the contextual issues and perceptions Political aspects surrounding the DHB funding allocations, developing a national picture of the impacts Following its introduction in 2003, of the PBFF based on regional perspectives. the PBFF has remained in place largely unchanged during the period of analysis, The patterns and content of media bridging both Labour- and National-led reporting on the PBFF have several implica- governments. Correspondingly, consec- tions. First, they suggest general discontent utive Labour and National-led governments with the PBFF model across the DHB sector. have defended the formula, though both Typically presented in a negative light, the parties have also criticised it during their PBFF was most commonly framed against time in opposition. While in opposition, a background of fi nancial struggle and National MPs highlighted the strain popula- resultant impacts on health services and tion-based funding placed on DHBs. Many staff. The underlying reasons centred on of National’s comments focused on the the failure of the health funding model to formula’s effect on health services, where adequately account for the pressures placed these services were generally being cut on DHBs as a result of various geographic or compromised.28 After being elected in and demographic characteristics. These 2008, National appeared to change their issues tended to be characterised as idio- rhetoric in defence of the formula. When syncratic challenges facing a given DHB; facing criticism over the formula, National however, aging populations and diffi culties often rebutted that a Labour government associated with either rapid or static popu- introduced it.29 The Labour-led Government lation growth and rurality were common (1999–2008) advocated the formula as a concerns. Although much was made of the method of fairly distributing funding across balance sheets of DHBs, contrasting funding the country. While in opposition, Labour allocations across the DHB sector created has called for comprehensive review of the a tacit atmosphere of ‘winners’ and ‘losers’ formula and has criticised the funding levels under the PBFF within the media coverage. received by certain DHBs and rural areas. Second, the geographic imbalance in In recent years, both National and Labour reporting volume suggests that frustration have acknowledged a lack of transparency with the PBFF is particularly keenly felt surrounding the PBFF and health funding in the South Island. One explanation for allocations and supported the need for this regional bias may lie in the legacy of greater clarity and public discussion around historic funding arrangements. The PBFF funding models.30,31 was introduced in an attempt to address historic imbalances in health funding Discussion between regions and to push newly established DHBs towards a position of funding The media has a well-established role equity. Funding allocations were imposed in framing the debate on health policy, gradually with the proviso that no DHB acting as a vehicle for both information and would ever receive an absolute reduction opinion on key policy issues.32–34 Interna- in funding. However, those DHBs deemed tionally, analysis of news media coverage to be over-funded under the new formula has been used to evaluate attitudes towards

received progressively smaller shares of reporting on the formula. Unmet need funding relative to other DHBs. For some features prominently outside of the context regions, such as Canterbury and Otago, this of the PBFF, though it likewise received generated considerable concern around the relatively little attention in the context of the impacts of a sinking fi scal lid in an already funding formula.50 37,38 strained fi nancial environment, as Third, the weight given to opinions of key refl ected in the media coverage. However, interest groups in the media points to the although contributing to the comparatively relative roles of different interest groups high volume of reporting in the South, framing media coverage as well as implying fi nancial pressures do not fully explain partiality in media coverage. The domi- variations in media coverage across the nance of opinions from those within the country. The focus on Vote Health share DHB sector suggests that DHBs themselves reductions was concentrated early on in the play an important role in infl uencing the analysis period and decreased over time as media’s narrative.32,51 Although often critical 39 funding allocations reached target levels, of the PBFF, many DHB comments were suggesting DHBs adapted to the new funding also comparatively conservative, possibly arrangements. Furthermore, while many pointing to acceptance of the PBFF within articles covering the PBFF mentioned DHB the sector or alternatively a symptom of defi cits in the South Island, they appeared political restraint. In comparison, the more far less frequently in articles about North incendiary comments offered by politicians Island DHBs, despite these DHBs posting illustrate the protean nature of politics, 40 numerous defi cits over the past 13 years. with political rhetoric linked to power. The regional variation in media coverage News media outlets may themselves have was likely also infl uenced by the rurality of an interest in infl uencing health policy. certain DHBs. Rurality is known to affect One indication of this is the dominance of the accessibility of health services in New coverage by the Otago Daily Times (ODT) Zealand,41,42 and creates a diseconomy of over the analysis period in combination scale for smaller DHBs (on a per capita with a particular focus on key themes basis).1,43 Some costs associated with rurality including rurality, transparency and the are adjusted for within the PBFF,2 though PBFF review. The ODT is New Zealand’s the numerous articles and comments iden- only nationally-owned newspaper and has tifying rurality as an issue suggests there a strong focus on policy issues affecting the may have been dissatisfaction with the southern regions. While the large volume of level or manner of adjustment for these articles in the ODT further highlights a sense South Island DHBs. There also appeared to of misgiving surrounding the PBFF model be a mismatch between those DHBs iden- in the southern regions, it also supports tifying rurality as an issue and those DHBs the notion of mass media acting as policy receiving the highest shares of the rurality contributors in the PBFF debate, rather than adjuster. For example, Northland and merely a conduit for the healthcare visions Waikato DHBs received among the highest of other key interest groups.36,52 Notably, shares,2 yet neither identifi ed issues with there was limited comment from inde- rurality in media coverage. These DHBs pendent commentators in the media, which have enjoyed relatively strong fi nancial may create barriers to impartial debate.32 health, which could have mitigated funding Furthermore, in combination with a focus on pressures associated with rurality.44,45 In fi nancial and health services diffi culties, the contrast, South Canterbury and Taranaki attention given by the media to voices with a DHBs receive relatively small shares of vested interest indicates a tendency towards the rurality adjustor, yet both identifi ed sensationalism in reporting on the PBFF.51 rurality as an issue. The prominence of the Fourth, temporal patterns in media rurality theme is perhaps also related to reporting suggest DHBs and politicians and the dominance of Southern reporting. As the media may be using pivotal points in the with rurality, ethnicity and deprivation are policy process to advocate for change to the factors which may affect the access and use PBFF model. The fi rst peak in media attention 46–49 of health services in New Zealand, yet coincided with the introduction of the PBFF. neither have featured prominently in media Nationally, this period also corresponded

with the greatest emphasis on Vote Health share reductions in the media, drawing Conclusion public attention to the potentially detrimental At the nexus of the themes emerging from effects of the new policy on DHBs. media coverage of the PBFF lie perceptions of fairness of the model. Although the role The second spike in the number of articles of the media in steering policymaking is and negative attitudes recorded coincided controversial it plays a crucial role in infl u- with the release of the Government’s most encing perceptions of the public.33,51,54 The recent review of the PBFF; over a third of PBFF may be intended as an impartial mech- articles mentioning a review were published anism for the distribution of health funding in that year alone. This period represented throughout the country,55 but public accep- a key window in which change to the PBFF tance of resource allocation decisions hinge was under consideration. The previous on value judgements and a sense that they review, conducted in 2007, failed to elicit result from a fair process.56,57 Our fi ndings a comparable spike in media attention, show that media coverage consistently links perhaps indicating rising interest and levels the PBFF to the cause and effects of fi nancial of unease with the current healthcare pressures experienced by DHBs throughout funding paradigm. the country, creating a sense that funding allocations are inequitable and that DHBs Strengths and are not entirely comfortable with the PBFF limitations model and its impacts on DHB income. The Our fi ndings contribute to a growing persistently high volume of reporting in the body of research on funding allocations in southern regions implies that the formula New Zealand,1,4,13–16 capturing a compre- has been particularly poorly perceived in hensive picture of reporting on the PBFF the South Island. At a national level, the over the majority of its lifetime and across pattern of media reporting and the themes the country. The combination of qualitative identifi ed suggest the PBFF has failed to and quantitative data offers insights into keep pace with the challenges facing DHBs the key patterns and themes surrounding such as aging populations, the diseconomies the PBFF as it is reported in the media, of scale related to rurality and health work- enhancing our understanding of the state of force recruitment and retention. health funding in New Zealand and how the While the PBFF may act as somewhat of a PBFF has been presented to the public. Our lightning rod for frustrations over fi nancial methodology is comparable to other media strain in the DHB sector, the media narrative content analyses.6,33 While some authors points to a number of lessons for policy- have argued that codes should only be makers. First, it highlights the need for created a priori to avoid the introduction of transparency around the PBFF model and observer bias,53 our justifi cation for a data- the process and principles underpinning driven method of creating codes is the need PBFF allocations. Second, the dearth of for fl exibility in a poorly researched area independent comment within the media is where existing literature could not guide an argument for policymakers to support us on the themes and issues we were likely the development of independent expertise to encounter. Although our study included on the PBFF model in order to provide all available news media stories over the credible and balanced viewpoints on the 2003–2016 period, scarce media coverage of distribution of health funding.33 Lastly, in some North Island DHBs makes it diffi cult to light of ongoing fi nancial disparities across identify issues and trends in those regions. the DHB sector, it reinforces the impor- Furthermore, the relatively small amount tance of monitoring of the impact of PBFF of research on the PBFF creates diffi culties allocations throughout the country. With when comparing our data and conclu- increasing healthcare costs combined with sions with other studies. Nevertheless, our an ageing population, a growing prevalence fi ndings are consistent with international of chronic illness and persistent disparities literature, demonstrating the importance of in healthcare access and outcomes, it will the news media in framing health funding become increasingly important that Vote policy debates.32,51,54 Health is distributed as fairly and as effec-

tively as possible. A greater understanding ﬁ nancial strife would be useful in furthering of the interplay between the PBFF and this goal and in optimising New Zealand’s other factors which may contribute to DHB healthcare system.

Competing interests: Nil. Acknowledgements: This study was funded by the University of Otago Dunedin School of Medicine. Author information: Aaron N Chester, Wellington School of Medicine, University of Otago, Dunedin; Erin C Penno, Otago Business School, University of Otago, Dunedin; Robin DC Gauld, Otago Business School, University of Otago, Dunedin. Corresponding author: Aaron N Chester, 88 Melrose Road, Island Bay, Wellington. [email protected] URL: http://www.nzma.org.nz/journal/read-the-journal/all-issues/2010-2019/2018/vol-131-no-1480- 17-august-2018/7663

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