Introduction

As in many Western countries, the role of voluntary agencies in healthcare provision in New Zealand has undergone significant change in recent years. At the macro-level, there have been clear shifts in the relationship between the state and the voluntary sector, with tensions evident between central and regional/district levels of decision making as health funding has been devolved but central constraints maintained (Health Services Research Centre, 2003). At a more micro-level there has been discussion of the functioning of voluntary organisations and the nature of volunteering itself, and the way that increased accountability imposed through contracts has required more sophisticated governance arrangements (Nowland-Foreman, 1998). In this chapter we examine these developments in more detail. We begin by providing some historical context and then examine the broad experience of health non-governmental organisations (NGOs) under state restructuring from the mid-1980s to 2005. The term ‘health NGO’ is in current use in New Zealand by government, health funders and voluntary agencies themselves to describe independent, not-for-profit organisations participating in health and disability sector activity. Drawing on the experience of three key health sector groupings – community mental health, primary healthcare and public health agencies – we review how key issues such as contracting and accountability relationships, management and professionalism and good service practice have been addressed since the 1980s. In particular, we show that the introduction of the internal market in the 1990s led not only to the rapid growth of health NGOs, but also to the emergence of substantial regional differences in contracting relationships and public accountability. At the same time, however, the new decentralised contracting environment, while encouraging innovation, undermined good service practice by making it more difficult for health NGOs to cooperate with each other and represent their communities effectively. The chapter has a particular focus on the period since the late 1990s when a more constructive relationship between health NGOs and the state began to evolve. Given the concentration of much research on larger voluntary organisations (Halfpenny and Reid, 2002), and the need for place- and sector-based interpretations of voluntarism (Fyfe and Milligan, 2003a, 2003b; Milligan and Fyfe, 2004), we conclude with a discussion of the implications of this experience at both macro- (governance and accountability) and micro- (NGO process and practice) levels.

Historical context

In the early days of organised government in New Zealand, the state resisted strongly any involvement in health and welfare provision, believing that this responsibility was better discharged by family and community assistance as the need arose (Thomson, 1998). Voluntarism in health services, therefore, has a long history. In the mid-19th century hospitals were established in the new colony by local subscription, with the state having minimal involvement, although from the late 19th century local authorities had a role in supporting both hospitals and charitable aid (Tennant, 1989).