The nature and effect of the relationships between stakeholders is a reoccurring theme throughout the cases studied. What is demonstrated by comparison of Pharmac to the other cases, is that in order for relationships to work well, they must be able to function within relationships of uneven power. This is demonstrated in the way Pharmac acts as a buffer between organisations, limiting the ability of strong stakeholders to influence the weaker. However, what is implicit within Pharmac, is that the organisations involved ultimately support Pharmac, otherwise it would not have remained for the time that it has.
Comparing Pharmac to the DHB system identifies some failures of the DHB system. The DHB system does not facilitate for uneven power distributions, something that should have been addressed in the original design of the system. This has continued over time, due to concerns by the Ministry about the ability of the DHBs to govern effectively. Meanwhile, it is in the interest of the Ministry to retain central power over the system, as ultimately, the Ministry has the most political accountability.
The relationship failure of the DHB system is reflected in the PHOs, whereby the relationships are designed to retain control over the PHOs, rather than to facilitate collaboration. The designs of the PHO and DHB systems have potential for them to work well together. However, because the PHOs are separate to the DHBs and the DHBs hold a role of accountability over the PHOs, the relationship between the two organisations becomes defined by this role.
The Maori Health Strategy then exemplifies what happens if structural design does not provide for how relationships should function. The Maori Health Strategy and Action Plans are vague and do not explain how the expected relationships between the various stakeholders are to be played out, resulting in a lack of relationships established, or established without effect.
This comes back to the capacity of the DHBs, where if they were functioning in the most effective way, with appropriate levels of autonomy, then they may be more effective at carrying out the strategies. Or, strategies such as this may not even be required, given that ideal DHBs should be able to identify areas of need within their local communities and provide resources accordingly, with appropriate guidance and support from the Ministry.