Privatisation by stealth, design or default? The future of New Zealand's health system.

New Zealand's health system is under sustained pressure, with worsening access to primary and specialist care, widening inequities and declining public confidence. In this context, there is an emerging but largely unarticulated shift towards increased reliance on private provision and private financing. This editorial examines whether this represents privatisation by design, default or drift, and considers the likely consequences. Evidence from New Zealand and comparable health systems suggests that increased privatisation is associated with higher costs, reduced equity and no consistent improvement in outcomes. Rising private insurance costs, outsourcing of elective services and public-private partnerships risk undermining the sustainability of the public system while failing to address the fundamental drivers of demand, particularly chronic disease and unmet need in primary care. These trends disproportionately affect Māori, Pacific peoples and low-income populations, raising concerns regarding Te Tiriti o Waitangi obligations. An alternative approach is proposed, centred on sustained investment in primary care and prevention, a clearly defined core package of publicly funded services and a cross-party health accord to ensure policy stability. The future of New Zealand's health system will depend on deliberate choices about equity, access and the role of the public sector.