New Zealand Medical Students’ Association

COMPILED POLICIES, FACT SHEETS

& POSITION STATEMENTS Updated June 2009

Contents:

1. Summary of all policies

2. Compilation of Policies

a. Medical Student N

b. Incentive Based Debt R

c. IBDR and Doctor Retention Summary S

d. Selection Policy (2008

e. Provisional Registration

f. ACCESS healthcare guidelin

g. Peripheral Learning

h. Rural Education Position

i. Full Fee Paying Students

j. Bonded Merit Scholarships

k. Step Up Scholarships

3. Pending Policies

a. Communications Policy

b. Funding for Affilia

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Medical Student Numbers Policy (2009)

Incentive Based Debt Relief Policy (2008)

Doctor Retention Summary Sheet (2008)

2008)

l Registration Policy (2007)

ACCESS healthcare guidelines (2007)

Peripheral Learning

Position Statement (2005)

Fee Paying Students Policy (2004)

Scholarships Factsheet (2004)

Scholarships Fact sheet (2004, updated 2009)

munications Policy

ated Groups

page 2

page 4

page 8

page 10

page 11

page 15

page 17

page 20

page 23

page 25

page 27

page 29

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1. NZMSA Summary of Policies

Medical Student Numbers Policy (2009)

This policy was written as a response to the National Government’s promise of fully funding 200

more medical student training places in New Zealand. NZMSA supports the goal of self-sufficiency of

our medical workforce and supports an increase in medical student places. However, we have

concerns about the available resources, the funding to improve current training facilities and the

impact an increase of numbers might have on the quality of medical education in New Zealand.

Incentive Based Debt Relief Policy (2008) and the IBDR and Doctor Retention Summary Sheet:

This policy explains why incentive based debt relief programmes should be introduced in New

Zealand as part of the framework for retaining more Kiwi doctors. It suggests some guiding principles

for use in the development in any such programmes. Key facts: In 2005 92% of medical students

graduated with a student loan, in 2007 the average student loan was $72,000. Debt is a key

migration factor and thus incentives should be targeted at debt relief.

Selection Policy (2008)

The process that NZMSA uses to select NZMSA members who apply to any advertised competitive

events or opportunities.

Provisional Registration Policy (2007)

The NZMSA supports provisional registration for trainee interns (TIs) to formalise the commitment

to producing medical graduates with the skills needed for safe practice as junior doctors and to

legally safe guard medical students, the universities and health care providers. The policy includes a

caution that provisional registration should be undertaken as a means of increasing learning

opportunities rather than increasing the service output of TIs.

ACCESS healthcare guidelines (2007)

ACCESS is the buzz word for improving healthcare in New Zealand and includes the six key ideas of

Admissions, Cost, Continuity, Education, Self sufficient and sustainable workforce, Solution based

endpoints. This document includes an overview of each of these key areas

Peripheral Learning

Teaching away from main campuses has a number of potential benefits and the NZMSA believes that

the use of innovative teaching locations should be encouraged. However, it is imperative that

students who are being taught outside of traditional facilities receive comparable opportunities,

support and training that they would benefit from otherwise. This policy has recommendations on

the provision of IT access, facilities such as accommodation and transport, learning opportunities

and student support.

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Rural Education Position Statement (2005)

Rural placements offer unique educational opportunities in primary, secondary, and lower tertiary

care and NZMSA believes that well resourced and well designed rural placements should be

developed and utilised. This position statement offers six guiding principles to be considered when a

rural placement is being developed or reviewed.

Full Fee Paying Students Policy (2004)

NZMSA is strongly opposed to domestic (NZ citizen or permanent resident) full fee paying students

for a variety of reasons listed in this policy. This policy also outlines concerns with international full

fee paying private medical students. It is also the first policy that states a concern about stretched

resources within the medical school.

Bonded Merit Scholarships Fact Sheet (2004)

The BMSs were initiated in 2006 and recognised academic achievement in the first year of a

student’s bachelor degree. It was worth a maximum of $3000 pa for 4 years as long as certain

conditions were met. After graduation, a student was bonded to work in New Zealand for the

equivalent number of years that they received the scholarship.

Step Up Scholarships Fact Sheet (2004, updated 2009)

Step up scholarships were introduced in 2004 to assist New Zealand students from low income

backgrounds. The student must contribute $1000 pa towards fees and is then bonded to work in NZ

for a maximum of four years after graduation. The scholarship will cover the rest of the compulsory

school fees.

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Medical Student Numbers Policy MAY 2009

Introduction

In 2008 the Medical Training Board recommended that the number of medical students training in New

Zealand should be increased by 100 places as one aspect of the strategy to tackle the medical workforce crisis

that we currently face. The New Zealand Medical Students’ Association (NZMSA) feel that there are some

specific challenges ahead to ensure that an increase in medical student numbers does not compromise the

quality and accessibility of medical education in our country.

The medical workforce crisis in New Zealand has been confirmed by several key reports. A recent World Health

Organisation report [1] found that 40% of New Zealand doctors were overseas trained, a figure that the

Medical Training Board would like to see reduced. In 2007, data collected suggested that 12% of newly

graduated doctors left the country before ever entering the New Zealand workforce [2], and a further 30% of

New Zealand doctors leave the country within three years of graduating from medical school [1]. This is

tantamount to a loss of approximately $14 million of training costs. New and creative solutions are required to

train and retain more Kiwi doctors.

One of the proposed mechanisms to address this workforce crisis is to increase the number of students taken

into New Zealand’s medical schools. In the last 25 years there have been only two small increases in medical

student numbers, once in 2003 and again in 2008. This is despite a significant growth in demand on the health

system due to a growing and aging population and a significant increase in the burden of chronic diseases such

as diabetes and obesity.

This policy represents a national student perspective to guide New Zealand medical schools, their associated

healthcare institutions and relevant decision-making bodies when increasing medical student numbers.

Aims The aims of this policy are to:

• ensure that any increase in medical student numbers is sustainable

• ensure that the high quality of medical education is maintained

• ensure that the burden of debt in order to finance an increase in medical student numbers does not

fall on students

• ensure equality of access to medical education for students from a diverse range of backgrounds

• ensure that the preferential entry schemes maintain a proportional number of the increase in places

• recommend that planning groups continue to closely liaise with relevant student associations and

maintain an understanding of the student experience of studying medicine as it changes over time

• ensure that the increase in numbers of medical students is translated to an increase in New Zealand

doctors working in New Zealand. This should be done by close liaison with postgraduate training

institutions and colleges in order to ensure adequate placements are available for New Zealand

graduates.

1. Zurn, P and Dumont, JC. Health workforce and migration: Can New Zealand compete? OECD Health Working Paper No. 33., May 2008.

Directorate for Employment, Labour and Social Affairs, Health Committee. World Health Organisation 2. Advanced Choice of Employment, ARMOS Statistics 2007

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Position Statement The New Zealand Medical Students Association (NZMSA) supports the goal of self-sufficiency of our medical

workforce and supports an increase in medical student places, with the following recommendations:

(A) Funding:

Funded medical places

Any increase must be of funded medical places. NZMSA opposes full or partial fee paying systems for reasons

of equity, educational capacity, and for the negative effects they would have on professionalism and

workforce distribution. The already unrepresentative demographics of medical students in our country would

only become further skewed. Please refer to our Full Fee Paying Students policy for further information.

Dedicated funding

Dedicated funding for extra resources (i.e. medical staffing and facilities) must be earmarked at both the

national and institutional levels to ensure the health system can cope with the increased demand in medical

training requirements.

Student fees and government support

Any increase in resourcing must not be funded by further increases in medical student fees. Both the initial

setup costs and any ongoing funding for the increase in medical student numbers must be provided by the

Government. Students are already facing significant issues with debt, and research has shown that higher

levels of debt increases rates of stress and distress in students [3], and influences choices about where to work

and which specialty to work in [4]. Any increase in levels of medical student debt will be detrimental to junior

doctor retention, and therefore numbers, the very problem an increase in medical student numbers is trying

to address. We reaffirm our position against the lifting of the fee maxima cap. Please see our Fee Maxima

Policy.

(B) Resourcing/Quality of Education:

Resourcing

Any increase in medical student numbers must be adequately resourced. The quality of education and

professional training cannot be compromised. Substantial funding will be required to support the provision of

appropriate resources and learning opportunities in a system already under a significant amount of strain.

Physical resources will need extension and development in all years of training at medical school. There must

also be incentives for practicing clinicians and academics to take on more teaching hours. These teaching hours

must be protected within the workplace environment.

Strategic planning

Strategic planning is required so that adequate resources and appropriate infrastructure are well in place to

ensure that the effects of increasing medical student numbers are managed effectively and are not

detrimental to the quality of medical education. Potential bottlenecks must be identified and systems

implemented to correct them. Anecdotally, students have initially identified bottleneck areas which are

already under strain. Please see Appendix 1. NZMSA recommends a review of current facilities and areas of

strain in each of the centres as soon as possible.

3. New Zealand University Students’ Association (NZUSA), New Zealand Medical Students’ Association (NZMSA), New Zealand Medical

Association (NZMA). Doctors & Debt: The effect of student debt on New Zealand’s doctors. Wellington. 2005. 4. Ward AM, Kamien M, Lopez DG. Medical career choice and practice location: early factors predicting course completion, career choice

and practice location. Medical Education. 2004;38:239-248.

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(C) Access

Currently there are designated medical student entry schemes for Maori, Pacific Island, and rural origin

students for reasons of affirmative action. NZMSA supports an equivalent proportional increase in these places

with any increase in medical student numbers.

NZMSA is aware that not all places on each scheme are filled year to year. This is not a reason to curtail a

proportional increase in these places. It is the responsibility of the wider educational sector to facilitate

appropriate opportunity for entry into these schemes and overcome any shortfalls in entry numbers. Please

see our Admissions Policy.

(D) Peripheral Placements

Support

There has been increasing development by New Zealand medical schools of placements in a wider range of

clinical teaching settings including rural clinics, rural hospitals, and community-based health services. NZMSA

believe these networks present a viable, valuable option for expanding clinical training beyond the urban

tertiary hospital setting. The utilisation of these satellite sites must be well-supported and sufficiently

resourced to ensure quality and consistency of training.

The use of peripheral hospital learning has been increased over the past few years with limited funding and

academic support for students. Please see our Peripheral Placement Policy.

Use of Private sector

We acknowledge that there are underutilised educational opportunities in the private sector. We would

encourage student involvement in any decisions made regarding medical student placements in private sector

learning environments. Please see our Private Sector Policy.

(E) A sustainable long-term approach:

Sustainable increase

Any increase in medical student numbers must be done in a sustainable fashion to avoid the ‘tsunami’ seen in

the United Kingdom and Australian medical workforces. Medical schools, District Health Boards, and post-

graduate training programmes must all be prepared for the increased numbers of graduates to ensure the

training paths for New Zealand doctors are not overwhelmed. We are concerned this would act as a driver for

New Zealand trained doctors to head overseas. Guarantees need to be made to ensure junior doctor positions

and training posts are available for the increased number of graduates.

Retention

Any increase in medical student numbers also needs to be backed by an increased focus on the retention of

junior doctors. Active steps such as incentive-based employment packages, smooth transition pathways and

other curriculum developments as delineated by the Medical Training Board must be implemented to promote

retention.

(F) Review

Any changes or developments in the health and education sectors affecting, or affected by, the increase in

medical student numbers should undergo regular review to ensure they are meeting the needs of both

students and the wider workforce. NZMSA asks to have formal involvement in any such review.

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Appendix 1 A few examples provided by students to NZMSA during a recent consultative process include:

• Medical student classes already exceed the sizes of some medical school lecture theatres.

• Group tutorial sizes are already too large for productive learning. Some small group tutorials have a

roll of 30 students.

• Some anatomical dissection laboratories already allocate over 12 students to a cadaver per session.

• Clinical teams are increasingly reaching capacity within central hospitals. Opportunities to be involved

in patient care or surgeries for example are already limited by the large number of students under

one consultant.

• There are currently far too few computers for medical students to access at some major centres. This

seems to be more of a spacing issue rather than with funding to provide more computers.

• Distant hospital learning is already having to be implemented with limited funding support for

students who often have to pay substantial costs when placed outside of their primary centre. (Refer:

‘Outreach/Placements’ below)

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Incentive Based Debt Relief Policy AUGUST 2008

Introduction Medical workforce shortages have reached crisis level in New Zealand. Loss of New Zealand

graduates overseas is one factor currently contributing to the workforce crisis. Push factors

identified for migration amongst junior doctors include high levels of student debt on graduation

and the lower remuneration rates offered in New Zealand compared to overseas, particularly

Australia. In 2005, 92% of medical students graduated with a student loan and an average debt of

$65 206; in 2007 the average student debt according to the Ministry of Health & Study Link was

$72,000.

We currently do not train or retain enough New Zealand doctors, and early migration soon after

graduation has further exacerbated workforce shortages. An inability to train and retain sufficient

doctors has resulted in an unhealthy reliance in New Zealand on overseas trained doctors (OTDs) to

man our workforce, and promoted a culture of locums at a junior doctor level, which exhaust health

budgets and provide only stop-gap solutions.

This document discusses innovative options to address New Zealand’s poor retention rates through

incentive based debt relief programmes.

Purpose This policy represents a national student perspective on the role of incentive based debt relief

programmes as a means to improve retention rates.

Aims The aims of this policy are to:

• Inform policy makers on the effects of incentive based debt relief programmes on the

workforce

• Provide guiding principles on any policy being formulated around the theme of incentives or

debt relief.

Incentive based debt relief Incentive based debt relief is a concept that provides a student loan relief to students upon

graduation in return for staying in New Zealand. Incentive based debt relief is preferable to bonding

schemes which bind students on entering medical school to prolonged periods of service upon

graduation which may have detrimental effects on both students and communities.

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The key aim of incentive based debt relief is to improve retention of New Zealand medical graduates

through the reduction of debt at the point of entry into the workforce. It recognises New Zealand

graduates for making the choice to stay in New Zealand and represents a long-term investment in

the future of our medical workforce by addressing the burden of debt, a key migration factor. We

believe this encourages graduates to see New Zealand as a viable place to practice in on graduation.

The NZMSA believes that a nation-wide and centrally-funded incentive based debt relief scheme

should be introduced at a central government policy level and offered to all New Zealand doctors on

graduation.

A national scheme would address the total supply side of the RMO or specialist shortage, whereas a

local incentive system may only address the distribution of these doctors without the clout to effect

significant change. However, a central scheme should not preclude the use of local or regional

incentives such as those currently offered by West Coast Health.

Australia runs a successful loan reimbursement scheme whereby doctors are offered a 20% payment

off their student loan for every year served in an area of workforce shortage. The United States of

America has several comparable programmes including the National Health Service Corps and Indian

Health Services. The NZMSA believes that a similar scheme could be established in New Zealand –

reimbursing new graduates for staying in New Zealand.

We believe that incentives should offer fair and adequate remuneration and preferentially target

New Zealand medical school graduates.

Recommendations 1. Incentives should be used to retain New Zealand doctors on graduation.

2. Incentives should be targeted at debt relief.

3. A nationally based and centrally funded scheme should be established at a policy level.

4. A central scheme should not preclude the establishment of local schemes.

5. Incentives should preferentially target New Zealand medical school graduates.

6. Incentives should provide fair and adequate remuneration.

7. Such remuneration should be in the form of direct student loan write offs proportional to

the length of service in New Zealand.

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DOCTOR RETENTION AND INCENTIVE BASED DEBT RELIEF

SUMMARY OF ISSUES

New Zealand faces a medical workforce crisis. We currently do not train or retain enough doctors to meet

the country’s needs. Loss of our junior doctors offshore soon after graduation has significantly

contributed to workforce shortages.

While many factors impact on doctor migration, high student debt remains a key driver for new

graduates. In 2005, 92% of medical students graduated with debt. The average amount owing at

graduation was $65 206, and 10% of graduates owed over $100 000.5 Two thirds of graduates cited they

would consider leaving New Zealand within 3 years to work overseas.ii Workforce shortages have

encouraged a locum market, which is costly and provides only short term stop gap solutions.

The New Zealand Medical Students’ Association (NZMSA) proposes Incentive Based Debt Relief as a

feasible solution to addressing retention issues and ameliorating our workforce crisis.

Incentive based debt relief (IBDR) is a concept that provides student loan relief to medical students upon

graduation in return for a service commitment to New Zealand. Incentive based debt relief is preferable

to bonding schemes which bind students on entering medical school to prolonged periods of service

upon graduation, and which may have detrimental effects on both students and communities.

KEY AIM OF IBDR

To improve retention of New Zealand medical graduates through the reduction of debt – a key migration

factor – at the point of entry into the workforce.

COMPARABLE SCHEMES

Australia runs a successful loan reimbursement scheme whereby doctors are offered a 20% payment off

their student loan for every year served in an area of workforce shortage. The United States of America

has several comparable programmes including the National Health Service Corps which offer up to 80%

off student loans over a 4 year period of service. The NZMSA believes that a similar scheme could be

established in New Zealand – reimbursing new graduates for staying in New Zealand.

RECOMMENDATIONS

o Incentives should be used to retain New Zealand doctors on graduation

o Incentives should be targeted at debt relief

o A nationally based and centrally funded scheme should be established at a policy level

o A central scheme should not preclude the establishment of local schemes

o Incentives should preferentially target New Zealand medical school graduates

o Incentives should provide fair and adequate remuneration

o Such remuneration should be in the form of direct student loan write offs proportional

to the length of service in New Zealand

5 Moore J, Gale, J, Dew, K et al. Student debt amongst junior doctors in �ew Zealand; part 1: quantity, distribution, and psychosocial impact. NZ Med J

2006;119:1229

ii Moore J, Gale, J, Dew, K et al. Student debt amongst junior doctors in �ew Zealand; part 2: effects on intentions and workforce. NZ Med J 2006;119:1229

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Selection Policy AUGUST 2008

Introduction NZMSA needs to run application and selection processes for a number of events and positions

provided to its members. In the process of selection NZMSA members may be called on to compare

the merits of their peers for a limited number of positions. These guidelines outline the rights and

responsibilities of applicants and selectors in an attempt to provide transparent and equitable

selection processes at all times.

Indications for implementing selection policy This policy applies to all competitive events or opportunities that NZMSA organises or advertises to

members. However, in exceptional circumstances, the President in consultation with the wider

executive may decide that a given selection process should occur outside the scope of this policy. In

this case all applicants must be aware that they are entering selection outside of the guidelines set

out by this policy. The processes outlined in this policy can not be abandoned once the selection

process is underway (ie if there are fewer applicants than places available)

This policy does not apply to the nomination and election of the NZMSA President or other NZMSA

executive office bearers.

Roles

Definitions

The Organiser(s):

The group, subcommittee or individual that need to select NZMSA members. For instance, the

external conference committee or the IMFSA delegation leader.

The Selector(s):

May or may not be the same person or people who are the organisers following discussion with the

External Officer. If the selection is to be made by a group of people (a Selection Committee) a

proposed Chief Selector must be clearly identified

The External Officer:

Oversees the actions of the Selectors, liaises between the organisers and the selectors if these are

separate groups, and ensures the spirit and rules of these guidelines are adhered to.

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Responsibilities

The Organiser(s)

The Organisers must approach the NZMSA President before calling for applications. The Organisers

are responsible for ensuring that the necessary processes of this policy are completed before any

advertisement is made to NZMSA members.

NZMSA President

The NZMSA President must is responsible for identifying and appointing an External Officer for each

selection process.

The External Officer

Each selection process is to be overseen by nominated individual appointed by the NZMSA

President. The External Officer must not be closely associated with the positions which are to be

selected; i.e., they must not be applying or have personal interest in the outcome of the process.

They are to be independent of the Organiser(s) and the Selector(s). The External Officer must liaise

with the Organisers and decide whether external Selectors are required, agree to the composition of

any Selection Committee and identify a Chief Selector.

The Organisers must have the following details agreed to by the External Officer prior to calling for

applicants:

� The number of positions available and the number of reserve positions (if any);

� The documents or details that will be requested from applicants;

� The criteria which will be used to assess these documents (either by the Organisers or

provided as guidelines to the Selectors);

� A timeline for the selection process.

The External Officer may request a revision of any part of the application and selection process for

an event. He or She may make suggestions to improve the process in the spirit of this policy, which

may include recruiting further external opinion.

The Chief Selector

The Chief Selector will be identified by the External Officer. The Chief Selector’s primary role is to

oversee the application process and ensure, amongst other things, that the following tasks are

completed:

� Ensure that the selection criteria and process have been agreed to with the External Officer

before any call is made for applications;

� Ensure that the position is suitably advertised;

� Acknowledge receipt of all applications;

� Arrange the meeting(s) at which selection will occur;

� Notify all applicants of the outcome of their applications;

� Ensure all applications (both electronic and hard copy) are deleted after the completion of

the event.

These tasks may be delegated to other members of the selection committee but it is the Chief

Selector’s responsibly to ensure that they do occur.

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Process

Notification of Selection

NZMSA members should be given a minimum of one week’s notice, usually by email, of any selection

process. This notice must include the following:

� The number of positions available;

� A clear list of any required documents and how they should be submitted;

� A clear closing date and time for applications;

� A copy of, or a link to, these selection guidelines and details of any expected changes in

protocol;

� The name and contact details of the Chief Selector and External Officer;

� Details of any possible costs incurred if the application is successful;

� The expected timeframe for outcomes.

Selection Criteria

The selection criteria should be a number of statements outlining desired characteristics, answers or

experience of applicants and directing the selectors to consider these. The criteria should also

address whether there will be regional quotas and whether previous selection for a similar event will

be impact on the current application.

Applications

Applications are to be emailed to a single email account and receipt confirmed to the applicant by

the Chief Selector. The Chief Selector must ensure that applications are deleted once the event has

concluded.

Closing Dates

Closing dates are to be strictly observed. Any extensions or allowances must be discussed with the

External Officer and cannot be granted by the Chief Selector alone.

Additional Guidelines

• In some situations it may be appropriate for applications to be de-identified prior to the

selection process. This should be agreed upon by the External Officer, Selectors and

Organisers;

• Personal recommendations or judgments from within the Organisers, Selectors, or NZMSA

are not appropriate. Applications are to be judged exclusively on the documents and

application submitted, in light of the agreed selection criteria. Any special circumstances

should be discussed with the External Officer and Chief Selector;

• No correspondence can be entered into with any applicant about the specific details of their

application;

• When emailed files are corrupted the Chief Selector should notify the applicant and provide

an appropriate extension for the files to be resubmitted;

• The selection criteria may be made available, retrospectively, to all applicants at the

discretion of the External Officer;

• Any disputes arising from an NZMSA selection process should be referred to the External

Officer in the first instance. If the dispute can not be resolved by the External Officer,

resolution should follow Section 14 of the NZMSA constitution (Mediation and Arbitration).

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• In circumstances where the EO believes that these guidelines have been breached or there

are significant procedural concerns about selection the EO should discuss this with the

President.

• NZMSA or nominated selectors will not discriminate against applicants on the basis of age,

gender, ethnicity, religion or sexuality.

• If all other applicant qualities are equal the selectors may support a demographic mix if this

would benefit the event

• In the event of insufficient applicant numbers a consensus decision should be reached

between the Organisers, External Officer and President about extending the application

deadline or other action.

• The Chief Selector, in consultation with the External Officer, may choose not to select any

applicants if there are no suitable applicants, irrespective of whether all available places

have been filled.

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Provisional Registration Policy

AUGUST 2007

Position Statement The New Zealand Medical Students’ Association (NZMSA) supports the introduction of a provisional

registration process for trainee interns, overseen by the Medical Council of New Zealand, in

conjunction with relevant stakeholders. We believe that the provisional registration formalizes the

commitment to producing medical graduates with the necessary clinical and professional skills for

safe practice, widens the scope of learning opportunities afforded to final year medical students;

while legally safe-guarding medical students, the universities, and health care providers.

Aims of provisional registration The NZMSA views the aims of provisional registration of trainee interns as being:

1. To develop the clinical and professional competencies required of graduating doctors, whilst

still in a university-regulated and educationally focused year

2. To formalize the scopes of practice within which the trainee intern can operate, particularly

with regard to independent performance of routine clinical taks

3. As a means of safe guarding students, universities, health care providers and patients

through a formal provisional registration process that ensures a trainee intern’s fitness to

practice at an expected level

4. To increase the awareness of the trainee intern to the professionalism demanded of them as

they move towards becoming a doctor

5. As an acknowledgment of the transitional nature of the trainee intern year; recognizing the

need to align the goals of the undergraduate curriculum with the requirements of

postgraduate practice

Cautions in introducing provisional registration The NZMSA supports the introduction of a provisional registration process with the following

cautions:

• That trainee interns must continue to be view as doctors-in-training and not as a service

commodity

• That the requisites for achieving provisional registration do not significantly add to the

workload of the current trainee intern curriculum

• That the obligations of trainee interns during the attachments – role, responsibilities, hours

and regulation of practice – continue to be set by the universities, and not influenced by the

DHBs or workforce shortages.

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The value of the trainee intern year lies in the educational opportunities it affords NZ

undergraduates to develop clinical judgment and competency in a supervised environment.

Therefore, provisional registration should only be undertaken as a means of heightening the

educational value of the year, rather than increasing its service output.

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ACCESS HEALTH ACCESS MEDICINE – 2007

Access to healthcare is one of the key determinants of a nation’s prosperity. It is also a visible measure by

which the New Zealand public is able to gauge the success or otherwise of a current government in their ability

to provide key public services. Increasingly shortages within the medical workforce are being identified at all

levels as barriers to New Zealanders accessing key healthcare services. Inequalities and misdistribution within

the existing workforce are also contributing to issues around equity of access to healthcare within New

Zealand. Medical workforce planning must begin with medical school admission and undergraduate education

if we are to equip tomorrow’s doctors with the skills and values necessary to serve in our communities.

Likewise we must re-evaluate what is happening at the undergraduate and early postgraduate level if we are

to truly understand the factors which shape our health workforce, to identify problems and to offer forward

solutions, in order to meet both current and predicted health workforce shortages. Ultimately as a country we

should by aiming at every level for a self sufficient and sustainable medical workforce that will meet the needs

of New Zealanders in the 21st

century.

To improve access to healthcare, we must focus on fostering a strong sustainable health workforce for New

Zealand.

A = Admissions – equitable, transparent, needs based

C = Cost – fees, funding, debt

C = Continuity – across curriculums, between sectors

E = Education –

S = Self sufficient and sustainable workforce

S = Solution based endpoints

A = Admissions

• Admission to medical school must reflect the health, geographic and cultural requirements of the

New Zealand population.

- Maori and Pacific students continue to be under-represented at medical school and in the

medical workforce.

- The benefit of considering ethnicity in selection is that people are more likely to use health

services if they feel culturally safe and identify with the provider (1).

- Students from lower socioeconomic groups and non-urban areas continue to be under-

represented in New Zealand medical schools.

- The ROMPE (rural origin medical preferential entry) programme has helped to address part

of this issue. Cost and access to tertiary education remain barriers.

• The vast majority of students able to meet established entry standards, including those from

‘preferential entry’ programmes complete their medical training and go on to become competent

doctors.

• There is a need for evidence-based admissions criteria that aim to select cohorts that are aligned to

the needs of the population, both clinically, culturally and academically.

C = Cost

• Medical school fees in New Zealand are amongst the highest in the world.

- The cost of a medical degree to a New Zealand student in 2007 is $60 000, or approx $11 000

per year

- 92% of medical students will take out government and private loans to meet these costs

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- The average medical student debt at graduation is $65 206, a quarter of students will owe

over $90 000.

- The cost of a medical degree has risen by $24 000 in the past ten years

- If fees continue to increase in line with current trends the average cost of a medical

education in ten years time will be close to $120 000

- Fees have continued to rise despite the Fees Maxima Policy as medical schools seek

exemptions to the cap.

• The cost is societal.

- 1/4 of medical students plan to leave New Zealand within their first year of graduation. Debt

is a significant driver behind this decision. This is a lost investment for New Zealand

governments, health boards and the New Zealand public.

- Debt drives students into specialties which are perceived as being better remunerated, and

into private practice, to the detriment of areas such as general practice and mental health.

This has significant implications for the wellbeing and primary healthcare of our

communities.

- Healthy populations are the goal of any government. Investment in health has far reaching

consequences for education, employment and the economy.

- Underfunding of the medical course by central government means asking young New

Zealanders to bear the cost of a medical education which will ultimately serve to benefit the

New Zealand public.

- This is unfair and ill aligned with the goals of improving healthcare and to the needs based

investment strategy of the tertiary education sector.

• Investment by governments in a medical education for young New Zealanders is an investment in the

future health of the nation.

C = Continuity

• Across curriculums

• Between sectors

- traditionally undergraduate medical training has been the responsibility of the tertiary

education sector and medical workforce the responsibility of the health sector.

- Consequently the funding, objectives and structural organization of the two have been

separated.

- However medical education and the development of the medical workforce need to function

as a continuum in order to optimize outputs.

- Alignment and cooperation between the education and health sectors is crucial.

- The need for intersectorial collaboration on issues of medical education and health

workforce must be made explicit.

- The Medical Workforce Taskforce has acknowledged the need for continuity and active

collaboration between the tertiary education and health sectors in order to effectively

address medical workforce issues.

- Likewise undergraduate medical education must be aligned to postgraduate training in order

to smooth transitions and provide continuity within the medical workforce.

E = Education for all

S = Self sufficient workforce

• New Zealand relies heavily on overseas trained doctors to man its health workforce.

- Up to 40% of the medical workforce in New Zealand in 2003 was made up of overseas

trained doctors (OTDs).

- The reliance on OTDs has occurred because of insufficient medical school places to meet the

needs of the country, poor retention of those doctors we do train in New Zealand and a

historical lack of workforce planning.

- The cost of recruiting and re-training and overseas trained doctor is higher than the cost of

funding a domestic place at a New Zealand medical school

• Reliance on OTDs reflects fiscal thinking

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- The longterm costs of recruiting sufficient OTDs to meet New Zealands workforce needs are

much higher than the costs involved in increasing the number of funded places in New

Zealand medical schools

- In the changing global medical market there is no guarantee that New Zealand will be able to

continue to attract the number of OTDs it requires to meet its workforce needs.

• New Zealand must aim for a self sufficient medical workforce in the future

- This involves improving retention of our current New Zealand trained doctors

- And increasing the number of funded places at New Zealand medical schools with a

concurrent commitment to ensuring there are adequate jobs available for new graduates

S = Solution based endpoints

• The previous decade has been a time of investigating and documenting the state of healthcare

provision in New Zealand, the extent of the health workforce crisis and the factors contributing to it.

There has been a push for evidence based reviews of medical admissions schemes, medical curricula

and workforce composition. We have quantified the problem, but we have offered little forward in

solutions.

• In order to promote change in the areas identified as being weak or outdated in the previous decade,

we must now move to focus our endpoints beyond data collection and onto solutions.

• Solutions the NZMSA has identified include:

• Debt: debt relief scheme; payment towards loan for years spent in NZ on graduation (not bonding but

incentive based)

• Fees: capping, freeze, increased funding

• Admissions: complex, intersectorial.

- Students who meet the needs of the population

- Students who have sufficient internal motivation, academic and personal skills to progress

through the course

• Self sufficiency:

- increase number of funded medical places

- retention of graduates; longterm outlook, job security schemes, impact of industrial climate

on retention

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Peripheral Learning Policy 2007

Overview

With a gradual increase in class size and greater interest in rural placements, a larger proportion of students

from both the Otago and Auckland Faculties of Medicine are undertaking parts of their clinical experience at

peripheral sites. Teaching away from main campuses has a number of potential benefits and the NZMSA

believes that the use of innovative teaching locations should be encouraged where possible. However, it is

imperative that students who are being taught outside of traditional facilities receive comparable

opportunities, support and training that they would benefit from otherwise.

Purpose

This policy represents a national student perspective to guide New Zealand medical schools, their associated

healthcare institutions and relevant decision-making bodies in developing off campus teaching arrangements

other than year long rural immersion programmes for their students.

Aims

The aims of this policy are to:

• Reduce disparity in peripheral teaching opportunities for all New Zealand medical students

• Provide evidence based best practice guidelines for off campus teaching

• Highlight common student logistic and lifestyle concerns regarding distance learning sites

Facilities and Cost

Students should be provided with the following IT facilities:

• 24 hour access to computer facilities, with internet and hard drive functions comparable to those

received at the student’s main campus

• Comparable access to scanning and printing facilities.

• Teaching and learning arrangements, including notes and coursework, should be available online, to

equalise access to resources for peripherally taught students.

Physical Resources:

Students should be provided the opportunity of timely access to main campus library resources not available

online.

Accommodation:

Accommodation of a reasonable standard should be provided to all students at peripheral sites where the

duration of placement is less than six months. In selecting accommodation, Faculties should consider whether

or not students will have access to transport and whether it is a safe walking distance from the hospital at

night. If this is not possible, students should be reimbursed for accommodation expenses at a reasonable

market rate, as agreed

Transport:

Students should be fully reimbursed for transport to and from their peripheral learning placements if they are

residing there for less than 6 months.

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Learning

Main campus teaching

All students regardless of location of placement should be entitled and funded to return to their main campus

for any whole-class or group teaching lasting at least two days.

Tutorials

Students at peripheral sites should be assured of a reasonable amount and quality of tutorials as students at

urban centres. The NZMSA encourages the use of videoconferencing and online learning facilities to enable

effective teaching and learning for peripherally placed students.

Clinical Teachers

Each peripheral placement must have a dedicated clinical supervisor that students can report to with any

concerns or queries. In addition placements should have a reasonable number of clinicians who are trained in

teaching methods and knowledgeable of the course objectives.

Clinical Experience

Students in peripheral sites must receive adequate supervision and have access to comparable clinical

experience.

Students should be given opportunities to enter patient care at any stage of the process and thus gain a more

holistic view of the healthcare process and the interdisciplinary nature of medicine.

Student Support

Orientation

Students at peripheral sites for greater than one week should be orientated by a nominated person

Should a student be finding their clinical experience challenging academically, all efforts should be arranged to

ensure they complete the learning necessary to meet the curriculum objectives.

Psychosocial

It should be recognised that students in rural areas may have additional needs for psychosocial support due to,

for example, social isolation, higher workload, and expectations from the community (both short- and long-

term).

Other services

Students engage in a variety of ‘informal’ experiences at traditional campuses from faculty and other providers

(for example OSCE revision sessions, DHB roadshow, careers evenings). Every effort should be made for

students at peripheral sites to travel to these events or for the events to be repeated off campus.

Contact

Students learning off campus should be provided with a contact person both at the peripheral site and main

campus with whom to discuss issues, logistics and other issues.

Feedback

Both students and teachers should have access to an effective feedback system on the rural curriculum, with a

transparent, closed feedback loop.

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Administration

Selection

Students should be offered the opportunity to volunteer for peripheral placements. Excess applicants should

be selected by random ballot. When there are insufficient volunteers students should be selected by random

ballot, balloted students should have a right of appeal – according to a defined a policy.

Students should be provided with defined learning objectives with a corresponding supporting curriculum on

all peripheral site placements at the onset of the year.

Students should be provided with a clear outline of the leave and remediation policy at the onset of the year

which should include a two step appeal process.

Students should be given the option to specify any peripheral sites where they have family or an inexpensive

choice of accommodation. In these conditions preference should be given to match these students to the

specified site.

Students should be notified of their peripheral placement at least 5 weeks ahead of schedule.

Each medical school should have an appointed staff member who is responsible for ensuring an effective and

transparent closed feedback loop for students and teachers.

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Rural Education Position statement – 2005

Overview

The NZMSA believes that a well-resourced and well-designed undergraduate rural curriculum can play a

significant and positive role in recruiting New Zealand trained doctors to work in rural areas. Current

undergraduate rural attachments can increase students’ intentions to work in rural New Zealand regardless of

their place of origin. Rural placements offer students a unique training in primary, secondary and lower

tertiary care. Australia and Canada have also experienced shortages of rural health professionals and are

investing significantly into rural medical education as an important measure to address this problem. Rural

curricula are part of developing the rural medical workforce, but will not replace efforts to make rural practice

a more competitive career option.

The NZMSA believes there is potential for medical students in rural areas to be of benefit to the communities,

practices and PHOs in which they are placed. We believe that students who are sought by their community

may enjoy their placement, connect with their communities, and learn, more. Students in demand from the

community will also attract more support from the community (social, financial and infrastructural), and so will

have better experiences. We also see benefit from encouraging repeated contact with the same rural

community, to build relationships of growing respect, involvement, and service provision.

We recognise that undergraduate rural placements may take many forms, and students will have a variety of

desires, goals and motivations. We believe the common thread of these programs should be exposure to

unique aspects of rural medicine, and to life in smaller communities. It is essential that rural placements, in

any form, are positive experiences for the students involved. If they are not, they will be of no benefit to any

stakeholder.

Position statements

1. That rural medical education must be appropriately funded

Rural medical education will be more expensive than urban education in large teaching hospitals, and this cost

cannot be borne by the students involved. Government should fund rural medical education appropriately.

2. That undergraduate rural education should be part of a vertically integrated rural career pathway

A coordinated and attractive career pathway is required to attract doctors to rural practice, and postgraduate

rural training should ideally be integrated with, and recognise, undergraduate curricula.

3. That collaboration between stakeholders is required for successful strategies in rural medical workforce

development

It is essential that trainees’ experiences are positive and that strategies are agreed. A close relationship and

good communication between stakeholders, including training institutions, trainee representatives, trainers,

employers, industrial representatives, health boards, government, and the rural community will make this

possible.

4. That students undertaking rural placements should not be disadvantaged

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a. There must be no compulsion or conscription to undertake rural placements for any students.

Conscription supports the view that rural practice is undesirable, reduces the chance that

students will develop a genuine desire for rural careers, and reduces the rural training

opportunities offered to students of metropolitan origin. Some students will find rural

placements more difficult, for example those with families or part-time employment in their city.

These students should be able to opt out.

b. Students should be given at least 3 months notice of rural placement

c. Transport costs must be reimbursed. Longer placements may require additional transport

provision during the placement for return visits to cities.

d. Accommodation must be provided or costs reimbursed, and must be of a suitable standard,

including study space.

e. Students must have free access to suitable information and communication technology, internet,

and teaching resources such as text books, including during after hours.

f. It should be recognised that students in rural areas may have additional needs for psychosocial

support due to, for example, social isolation, higher workload, and expectations from the

community (both short- and long-term).

5. That teaching in rural placements should be supported, remunerated and quality controlled

Teachers in rural areas are a valuable and scarce resource for both training and mentoring. Clinical teachers in

rural areas should have appropriate training and suitable remuneration to ensure students learning and

assessment needs are met. Appropriate payment will portray students as a benefit, and not a burden, on their

clinical colleagues and patients. Clinical trainers in rural areas may well extend beyond medical practitioners

to include the range of health care providers in rural communities.

In situations where rural centres cannot provide teaching, proven distance-learning methods should be used,

with quality teleconference (or videoconference) equipment.

Both students and teachers should have access to an effective feedback system on the rural curriculum, with a

transparent, closed feedback loop. A rural coordinator should be established to ensure quality rural

placements, and appropriate student support.

6. That rural curricula, and rural practice should be promoted as a positive and attractive option for

students and doctors

The NZMSA strongly supports the aims and activities of the Aotearoa Rural Health Apprentices (ARHA) and the

local rural health clubs in promoting rural health. These organisations should be supported by rural health

stakeholders. Rural medicine should be promoted by medical schools as well. In particular, promotion should

target first year students and current rural-origin students. Research into rural health should be encouraged

and publicised. Students on rural placements could also engage with rural secondary schools to encourage

rural medical careers, and advertise the Rural Origin Medical Preferential Entry (ROMPE) scheme.

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Full Fee Paying Students Policy – AUGUST 2004

Domestic Full Fee-paying Medical Students

The New Zealand Medical Students' Association (NZMSA) is strongly opposed to domestic (New Zealand

citizen or permanent resident) full fee-paying medical students for the following reasons:

• Entry to medical school should not be based on students' ability to pay.

• Entry to medical school should be based on students' academic ability, personal attributes and

aptitude.

• Accepting full domestic fee-paying medical students will create a two-tiered system of medical

education one for students who gain entry on academic ability, personal attributes and aptitude, and

another for students ranked lower on the above criteria but who have the ability to pay.

• Accepting domestic full-fee paying medical students will skew the demographics of medical students

further away from those that reflect New Zealand's general population.

• Inadequate funding of New Zealand medical schools should be addressed by increased funding from

central government, not the introduction of domestic full-fee paying medical students.

• New Zealand medical schools have already reached or exceeded their capacity in many areas, and

increasing student numbers may compromise the education of all medical students. The NZMSA has

particular concerns about the impact of increased student numbers on many resources, including:

tutorial rooms; lecture theatres; labs; group sizes; library space; library resources; clinician teaching

time; and patient access.

• Accepting domestic full-fee paying medical students will not address current workforce shortages

because:

o it is unlikely that they will develop a sense of obligation or loyalty toward to New Zealand;

and

o they will be more likely to select specialities based on financial remuneration.

International Full Fee-paying Medical Students

The New Zealand Medical Students' Association (NZMSA) is concerned about increasing the numbers of

international full-fee-paying medical students for the following reasons:

• Although the NZMSA view the cultural diversity that international medical students bring to New

Zealand's medical education as beneficial, it believes that a good balance already exists with the

current numbers.

• Entry to medical school should not be based on students' ability to pay. The NZMSA understands the

merit in accepting international full-fee paying medical students from government assisted

programmes and scholarships (particularly from countries that do not have their own medical degree,

for example the Seychelles). However, the NZMSA disagrees with private international full fee-paying

medical students.

• Inadequate funding of New Zealand medical schools should be addressed by increased funding from

central government, not an increase in the numbers of international full-fee paying medical students.

• Medicine is distinct from other qualifications offered by New Zealand as education 'exports'. Medical

schools rely on the general public's good faith to consent to student contact and involvement with

their care. The NZMSA believes that considerable good faith is generated from the concept of

training New Zealand doctors for New Zealanders. The NZMSA's position is that patient's good faith

should not be traded on to generate revenue from other country's medical students. There is also a

risk of losing that good faith, which would adversely affect the education of all medical students.

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• The cultural appropriateness of international students is a concern, particularly where inadequate

support exists for cultural differences during training across several areas – from tutorial participation

to student/patient contact.

• New Zealand medical schools have already reached or exceeded their capacity in many areas, and

increasing student numbers may compromise the education of all medical students. The NZMSA has

particular concerns about the impact of increased student numbers on many resources, including:

tutorial rooms; lecture theatres; labs; group sizes; library space; library resources; clinician teaching

time; and patient access.

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The Bonded Merit Scholarship Fact Sheet

The Bonded Merit Scholarship began in 20061

and recognises academic achievement in a student’s first year of

a bachelor degree. In 2006, 500 students were awarded the scholarship and doubled to 1000 recipients in

2007 and 2008. It is planned to further increase the number of students to 1500 for the 2009 academic year2.

Tenure (from the second year of study):

• Full time student = a max of 4 years @ $3,000/year

• Limited full time due to illness/disability = unlimited timeframe but $12,000 max.

Eligibility3

• Only for a student completing their first bachelor degree.

• ≥B average in first year (note - an intermediate year of study as a prerequisite to a degree programme

can also be counted as “first year”).

• Requires academic transcript as evidence for grade history (May also ask for evidence of

awards/prizes received and 2 academic references)

• Cannot be held with another government funded stipend or scholarship for course fees.

Conditions4

• Bonding: Bonded to remain in NZ for a period equivalent to the length of the scholarship (max of 4 years).

o Leave: You can leave NZ for 365 days over the total of the 4 years bonding period in addition

to the 4 weeks per year.

o Breach: A graded repayment of the scholarship received up until the point is required,

depending on when the conditions were breached (80%, 70%, 60% repayment required if

breach occurred within 1,2 or 3 years respectively).

• Maintenance of a B average is circumstance related: The student will still receive payments if the r B

average was not maintained because of circumstances beyond their control (e.g. accident or illness). If the

reasons were within the students control and:

o Over ½ the course was passed & the student continues with the degree → student WILL be

bonded but will NOT have to repay payments received.

o Over ½ the course was passed but the student does NOT continue with the degree (or, ½ the

course was NOT passed) → student WILL be required to repay payments received (see

“breach” sub-section).

• Part-time study: In the 1st

year of receiving the scholarship the student must be studying full time. From

the 2nd

year of receiving the scholarship the student may be able to study part-time provided they get

Limited Full-time approval (i.e. have an illness/disability). If approval is not given and part time study is

pursued, this will be classed as a breach of contract and the student will need to repay payments received

(see “breach” sub-section).

• Postponement: Can only take place after receiving the scholarship for one year, can only be for 1 year, and

is only approved if the student has a special circumstance (i.e. family, personal, financial reasons that

affect the student’s ability to study).

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• Withdrawal: Will have to repay the scholarship unless the withdrawal was for reasons beyond the

student’s control.

• Overseas study: Requires the approval of the students education provider, and a Bonded Merit

Scholarship Overseas Study application form to be approved, Overseas study with no approval =

repayment of scholarship (see “breach” sub-section).

• Changing courses: Discuss with Studylink – may be able to change but the new course must be a bachelor

or post graduate course.

Sources

1. http://www.beehive.govt.nz/speech/new+zealand+union+students%E2%80%99+associations

2. http://www.studylink.govt.nz/media/archives/2008/2008-budget-changes.html

3.http://www.studylink.govt.nz/thinking-about-study/what-studylink-offers/scholarships/bonded-merit-

scholarship.html

4.http://www.studylink.govt.nz/thinking-about-study/your-responsibilities/scholarship-

responsibilities/index.html

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The Step Up Scholarship Fact Sheet

In 2009 the Government announced the disestablishment of the Step Up Scholarships in its annual budget. The

following document provides a brief overview about the scholarships and reasons as to why the Government

should consider reinstating them.

The Step Up Scholarship began in 20041 and aimed to assist students from low income backgrounds achieve

tertiary education.

Total number of applications versus total number of awards2:

2003/04 unknown applicants 2004 213 awarded

2004/05 764 applicants 2005 235 awarded

2005/06 1012 applicants 2006 362 awarded

2006/07 956 applicants 2007 320 awarded

2007/08 1739 applicants 2008 unknown awarded

Reasoning behind the scholarship:

Medical education is expensive. The average medical student will graduate with $76,000 of debt. Those from

lower socioeconomic backgrounds are more likely to see this as a barrier to study, and are less likely to choose

to study medicine because of it. The scholarship was important in ensuring equity of access to a wide variety of

New Zealanders who wanted to study medicine.

Not only does this scholarship encourage high school students to entertain the possibility of studying

medicine, but it also shows the government’s willingness to support students in becoming doctors. Research

has consistently shown that high levels of medical student debt has an adverse affect on the medical

workforce. Those with higher levels of debt are more likely to specialise, more likely to work overseas and

more likely to take up locuming positions.

The current workforce crisis means that we need more General Practioners and General Physicians working in

more rural areas. In low socioeconomic areas there is a shortage of doctors. Given that junior doctors are

more likely to return to their area of origin, it makes sense that the government would support students from

targeted areas of need. Students are more likely to address a need in their local community if they graduate

with lower levels of debt and feel a degree of responsibility to work for the government that funded their

education.

It seems strange that a government that will fund an increase in medical student numbers and support a new

initiative, the Voluntary Bonding Scheme, to meet workforce needs and reduce student debt has dis-establish

this scholarship programme.

30

Scholarships awarded prior to April 2009 will continue to be honoured, but no new scholarships will be

offered. We are keen to hear from any students who have benefited from a scholarship and would be happy

to share their story.

Details of the scholarship:

Tenure: The entire length of an approved degree

Pays the compulsory course fees minus $1000/year

Eligibility3-4

• Only for NZ citizens/permanent resident students less than 24 years old entitled for a student allowance

when starting their first approved bachelor degree (which includes BHSc, BSc and MBChB).

• Student prepared to pay $1000 per year of study towards compulsory course fees.

• Cannot be held with another government funded stipend or scholarship for course fees.

Conditions3-4

• Bonding: Students are bonded to remain in NZ for a maximum period of 4 years over the 5 year period

following course completion.

o Leave: The student can leave NZ for 365 days over the 5 year bonding period in addition to 4

weeks per year.

o Breach: A graded repayment of the scholarship received up until the point of breach is

required, depending on when the conditions were breached (i.e. for scholarships >3years,

80%, 70%, 60% and 40% repayment required if breach occurred within 1,2, 3 or 4 years of

course completion, respectively).

• Pass over half the course: If the student fails for reasons outside their control (i.e. illness/accident) they

can continue to receive the scholarship. However, if failure occurs for reasons within the student’s control

a probation period of a year will apply (i.e. study for a year without the scholarship, pass half the year and

still be eligible for a student allowance the following year).

• Part-time study: The student may be able to study part-time provided they get Limited Full-time approval

(i.e. has an illness/disability).

• Postponement: Once the course is started the student can postpone their scholarship for a maximum of 1

academic year, and must resume study at the start of the first semester of the following calendar year.

The student will only need to re-establish their right to be paid a student allowance if they withdraw for

reasons within their control (i.e. reasons other than sickness/accident). A second postponement will be

treated as a ‘withdrawal’.

• Withdrawal: Will not be eligible for further scholarship payments if the student does not intend on

returning to study. No repayment of any scholarship money that the student received is required.

• Changing courses: Discuss with Studylink – must change to another approved course.

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References

1. http://www.beehive.govt.nz/speech/new+zealand+union+students%E2%80%99+associations

2. http://www.msd.govt.nz/media-information/press-releases/2008/pr-2008-05-07.html

3. http://www.studylink.govt.nz/thinking-about-study/what-studylink-offers/scholarships/step-up-

scholarship.html

4. http://www.studylink.govt.nz/docs/brochures/final-sus-terms-and-conditions-2008.pdf