Not a money problem: what Health NZ reveals about your business

I received an email this week from a political group with the headline: an American health policy academic, Ezekiel Emanuel, telling us our health system was "solidly middle" by rich-country standards and that we don't need to spend more, just spend better.

And do this by fixing incentives, infrastructure and information.

My first reaction was the usual one. I don't love it when foreign academics fly in to tell us how to run our country. It's frequently advice mired in their own weird system. The American health system is NOT the model we should be importing from.

But broken clock, twice a day. The three things he pointed at are the same three things I push with every founder I work with.

Information. Measures, data, insight. What's working, what isn't, what return are you getting forward and back. If you can't see it, you can't manage it.

Incentives. Reward great work. Penalise poor work. Communicate ruthlessly what good looks like and what people are trying to achieve. Then act on it. People will do exactly what you measure and reward them on. Nothing else.

Infrastructure. The systems that hold all of this together. Without them the first two collapse.

You can run a hospital on these three. You can run a SaaS company on them. You can run an advisory practice, a manufacturing business, a podcast network. The principle doesn't change with the industry. What changes is whether the people in charge actually use them.

Quick context on why this is on my mind. I've spent the last few months dealing with the New Zealand health system up close. An unpleasant and vaguely exotic injury (not the broken wrist in the photo - that's been simple), multiple touchpoints, A&E (so therefore ACC), surgeons, scans.

Then, surgeons who don't show up. 30-minute lateness as standard. Quoted data that turned out to be wrong. A 10-hour wait in A&E. A request to stay in overnight to wait for someone to come and look at me - wasting a bed I didn't need - because nobody had been seen all day. I'm not airing this for sympathy. I'm airing it because it's the cleanest worked example I've ever had of an organisation broken at the operating level, not the funding level.

And the funding level isn't the story anyone thinks it is.

Health NZ now runs on a NZ$30 billion annual operating budget. Spend has gone from $18.2 billion in 2018-19 to $29.6 billion in 2024-25 - up 62% in six years. The 2024/25 result was a $947 million deficit (better than the $1.1 billion budgeted deficit). A Deloitte review last year identified "a loss of effective financial control" as the central cause of the financial decline. The Prime Minister called it a "massive bureaucracy" with a lack of performance management. And what are we getting for this extra spend?!

Controversial opinion... that's not a money problem. That's an operating problem. Information, incentives and infrastructure all failing at once. And operating problems are exactly the thing founders should pay attention to, because the same disease lives in their own businesses, just smaller.

This is the bit that should resonate for any founder reading. The reason Health NZ is in the state it's in is not unique to government. It's the same set of failures I see in private businesses every week. Unclear measures. Bonus structures that reward the wrong behaviour, or no bonus structure at all. Systems built in 2014 that nobody's touched since. People in roles they're not equipped for, kept there because nobody wants the conversation. Capital sloshing around without a clear ROI test. Sound familiar?

The difference between Health NZ and your business is that you don't have $30 billion to hide the problem with. Whatever's broken in your operating model shows up in the P&L within a quarter. Which is, frankly, lucky for you.

So here's a question worth pondering: If a Crown Observer was appointed to your business tomorrow - same brief as for Health NZ, "go in and find out what's actually going on" - what would they find?

Would your information be tight? Would your incentives be rewarding the right behaviour? Would your infrastructure be holding it together, or held together with duct tape and good will?

If the answer to any of those is uncomfortable, you don't need an American academic to tell you what to do. You already know.

You just have to do it.

Cheers,
Josh